After a new kidney allocation system (KAS) in the United States was implemented in December 2014, the rate of deceased-donor transplantation increased and the risk for graft loss and patient death decreased among patients with a dialysis vintage of 6.5 years or more prior to placement on the kidney transplant waitlist, a new study finds. Most patients with a long dialysis vintage, however, still never get placed on the waitlist.
The policy change aimed to minimize disparities in access to transplantation. The wait-time accrual for deceased donor kidney transplantation was changed from the date of first waitlisting to the date of first chronic dialysis treatment. To understand the real effects of the policy change, investigators compared 7044 patients with a dialysis vintage of 6.5 years or more who were waitlisted before or after KAS implementation.
The new policy was significantly associated with a 3.1-fold increased rate of deceased donor transplants, John S. Gill MD, MS, University of British Columbia, Vancouver, Canada, and colleagues reported in the American Journal of Kidney Diseases. It was also significantly associated with a 26% lower risk for patient death and a 34% and 37% lower risk for all-cause and death-censored graft loss, respectively. Adjusted death rates were similar in the pre- and post- KAS cohorts, suggesting the improvement survival after KAS was not related to changes in dialysis- or transplant-associated mortality.
Still, the proportion of patients with a long dialysis vintage who were never waitlisted for transplantation remained high. The proportion of never-waitlisted patients was 73.6% in December 2011 and 74.0% in December 2017, the investigators reported. Rates varied across US states.
“The study findings demonstrate that the change in kidney allocation policy was successful in providing access to transplantation, once waitlisted, for a disadvantaged patient population that might have otherwise never been considered for transplantation,” Dr Gill’s team wrote.
The authors also noted, however, that their findings “demonstrate the limited impact of this policy change in isolation to increase referral and activation to the transplant waitlist for disadvantaged patients with obvious barriers to transplantation and suggests the need for broader collaboration between dialysis providers and transplant programs to ensure that patients of long dialysis vintage who might benefit from transplantation are not forgotten.”
Kadatz M, Lan JH, Brar S, et al. Transplantation of patients with long dialysis vintage in the current deceased donor Kidney Allocation System (KAS). Am J Kid Dis. Published online March 16, 2022. doi:10.1053/j.ajkd.2022.01.429