Disparities Persist in Early Kidney Transplantation Despite Policy Changes

The 2014 Kidney Allocation System may have exacerbated some inequalities for racial minorities and patients on Medicare.


Highlights

  • The proportion of preemptive transplants—when a patient receives a kidney transplant before starting dialysis—increased after implementation of the 2014 Kidney Allocation System from 9.0% to 9.8% of all kidney transplants.
  • Increases in preemptive transplantation were not shared equally among all patient groups, however, and disparities were actually exacerbated for Black and Hispanic patients and for patients on Medicare. 

Newswise — Washington, DC (September 26, 2019) — A recent analysis reveals persistent disparities in preemptive transplantation, when a patient receives a kidney transplant before ever starting dialysis, despite efforts to correct inequalities in transplantation. The findings appear in an upcoming issue of CJASN.

Preemptive transplantation is considered the best treatment option for patients with chronic kidney disease that has progressed to kidney failure, but its availability is limited by the shortage of organ donors relative to patients on the waitlist for a new kidney and failure to have patients listed in a timely manner. The system for matching kidneys from deceased organ donors to waitlisted candidates was overhauled with the 2014 Kidney Allocation System (KAS) to try to correct some inequalities in transplantation. To assess what effect KAS has had on preemptive transplantation, a team led by Sumit Mohan, MD, MPH, and Kristen L. King, MPH (Columbia University Irving Medical Center) examined information on all adult deceased donor kidney transplant recipients in the United States from 2000–2018.

Preemptive transplant recipients were more likely to be white, older, female, more educated, hold private insurance, and have kidney failure not caused by diabetes or hypertension. The proportion of preemptive transplants increased after implementation of KAS from 9.0% to 9.8%, with a 10% higher likelihood of preemptive transplantation after KAS was implemented compared with before. Increases in preemptive transplantation were not shared equally among all patient groups, however. The sociodemographic and clinical disparities in preemptive transplantation that were present in the pre-KAS era still exist under KAS, and disparities were actually exacerbated for Black and Hispanic patients and for patients on Medicare. Patients with private health insurance had 5 times the odds of receiving their transplant preemptively compared with patients on Medicare. 

“With new attention on policy reform around kidney disease and transplantation, our research can help inform where efforts are needed to achieve more equitable care for kidney disease patients,” said Dr. Mohan. He noted that the Executive Order on Advancing American Kidney Health issued in July identified increasing kidney transplantation and better treating/preventing kidney disease during its early stages as top priorities for improving the kidney health of individuals in the United States.

An accompanying editorial notes that “factors related to access to pre–end stage kidney disease nephrology care, quality and timing of transplant education, assessment of transplant eligibility, and receipt of preemptive transplant referral, particularly for racial/ethnic minority patients and patients with lower socioeconomic status likely stand at the forefront of barriers to eliminating these disparities.”

Study co-authors include Syed Ali Husain, MD, MPH, Zhezhen Jin, PhD, and Corey Brennan, MPH.

Disclosures: Outside of this study, Dr. Mohan reports personal fees from CMS and Kidney International Reports. Dr. Mohan also reports being a member of the Angion Scientific Advisory Board and the UNOS data advisory committee. Mr. Brennan, Dr. Husain, Dr. Jin, and Ms. King have nothing to disclose. Dr. Mohan is supported by grants from the National Institutes of Health, National Institute of Diabetes and Digestive Kidney Diseases (R01 DK114893 and U01 DK116066). Dr. Husain is supported by the Young Investigator Award from the National Kidney Foundation.

The article, entitled “Trends in Disparities in Preemptive Kidney Transplantation in the United States,” will appear online at http://cjasn.asnjournals.org/ on September 26, 2019, doi: 10.2215/CJN.03140319.

The editorial, entitled “Persistent Disparities in Preemptive Kidney Transplantation,” will appear online at http://cjasn.asnjournals.org/ on September 26, 2019, doi: 10.2215/CJN.09800819.

Since 1966, ASN has been leading the fight to prevent, treat, and cure kidney diseases throughout the world by educating health professionals and scientists, advancing research and innovation, communicating new knowledge, and advocating for the highest quality care for patients. ASN has more than 20,000 members representing 131 countries. For more information, please visit www.asn-online.org or contact the society at 202-640-4660.

The content of this news release is solely the responsibility of the authors and does not necessarily represent the official views or imply endorsement of the National Institutes of Health.

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