Despite the new Kidney Allocation System (KAS) implemented in 2014, disparities still exist in preemptive transplantation, according to a new online report from the Clinical Journal of the American Society of Nephrology

The proportion of preemptive transplants, in which a patient receives a deceased donor kidney (DDK) transplant before starting dialysis, increased from 9.0% pre-KAS to 9.8% post-KAS, Sumit Mohan, MD, MPH, of Columbia University in New York, and collaborators reported. A subset of patients benefitted the most. After KAS, preemptive transplant recipients were more likely to be older, white females with higher education, and to have private insurance. These recipients were less likely to have the most common causes of end-stage kidney disease (ESKD), diabetes and hypertension.

The 2014 policy change widened gaps in insurance status, race, age, and Human Leukocyte Antigen zero-mismatch, according to the investigators. Compared with privately insured patients, Medicare patients had significant 74% decreased odds of preemptive transplantation pre-KAS and 80% decreased odds post-KAS in adjusted analyses. Compared with whites, blacks had 52% significant decreased odds of preemptive transplantation pre-KAS and 59% decreased odds post-KAS. Hispanics had significant 57% decreased odds pre-KAS and 60% decreased odds post-KAS.

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Older adults fared better. For every 10-year increase in recipient age at transplant, the adjusted odds of preemptive transplantation increased from less than 1.7-fold pre-KAS to 2.1-fold post-KAS.

“Because preemptive transplantation is associated with improved patient and graft outcomes, further efforts to reduce disparities in access on the basis of sociodemographic characteristics are needed to achieve more equitable outcomes for patients with ESKD,” Dr Mohan’s team stated.

For the study, investigators used Scientific Registry of Transplant Recipients (SRTR) 2008 to 2018 data from 157,073 first-time, DDK transplant recipients, including 111,153 patients who received a transplant pre-KAS and 36,584 patients who received a transplant afterward.

Additional work is clearly required to address barriers, Tanjala S. Purnell, PhD, MPH, and Deidra C. Crews, MD, ScM, of Johns Hopkins Medical Institutions in Baltimore, commented in an accompanying editorial.  

“Factors related to access to pre-ESKD 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,” they wrote.

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King KL, Ali Husain S, Jin Z, et al. Disparities in preemptive kidney transplantation in the United States [published online August 14, 2019]. Clin J Am Soc Nephrol. doi:10.2215/CJN.03140319

Purnell TS and Crews DC. Persistent disparities in preemptive kidney transplantation [published online August 14, 2019]. Clin J Am Soc Nephrol. doi:10.2215/CJN.09800819