Many optimal patients for kidney transplantation still face delays in being placed on the waitlist, with evident disparities by sex, race, insurance coverage, employment status, and income, a new study finds.

Patients with an estimated post-transplant survival (EPTS) score of 20% or less have the lowest risk of transplant failure and warrant priority for high-quality deceased donor kidneys. These include younger patients without diabetes who have not had a prior transplant and with little or no time on maintenance dialysis.

Among 42,445 patients with top EPTS scores (mean age 38 years; 57% male; 59% White; 31% Black), only 7922 were preemptively waitlisted, Jesse D. Schold, PhD, of Cleveland Clinic in Cleveland, Ohio, and colleagues reported in the Journal of the American Society of Nephrology. For the remaining 34,523 patients receiving dialysis, waitlist placement within 3 years was 37%. The waitlist rate for patients without any comorbidities was higher at 48%, but still represented less than half of all eligible patients.

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Black (vs White) patients, women, those without private health insurance, the unemployed/retired, and residents of low income neighborhoods were less likely to be waitlisted. Patients with diabetes, hypertension, and obesity also had lower likelihood of placement. Receiving nephrology care prior to dialysis increased the odds of waitlisting by 41%.

A total of 61% of patients initiating dialysis lost their EPTS priority status within 30 months, compared with 18% of preemptively-listed patients, the investigators reported. Deceased and living donor transplantation rates within 3 years were 5% and 6%, respectively, for patients who initiated dialysis, compared with 26% and 44% for preemptively-listed patients.

“Although the number of organs available for transplant is insufficient for the current waitlist population, these data suggest many more patients would likely meet eligibility for transplant, and the scarcity of donor organs in the population relative to those who may benefit is much more pronounced than commonly depicted,” Dr Schold’s team wrote.

In an accompanying editorial, John S. Gill, MD, of St. Paul’s Hospital in Vancouver, British Columbia, Canada, and colleagues stated: “Strategies to fast-track the waitlisting of patients for whom the benefits of transplantation are particularly time sensitive and specifically address disadvantaged populations should be implemented.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 


Schold JD, Huml AM, Poggio ED, et al. Patients with high priority for kidney transplant who are not given expedited placement on the transplant waiting list represent lost opportunities. J Am Society of Nephrol. Published online June 17, 2021. doi:10.1681/ASN.2020081146

Gill JS, Butler CR, Powe NR. Primacy in kidney allocation: Does it alleviate the barriers to transplantation? J Am Society of Nephrol. Published online June 17, 2021. doi:10.1681/ASN.2021040474