Dual impact of donor service area removal from kidney allocation system and Coronavirus Disease 2019 pandemic on access to transplantation

Abstract

Introduction Donor service area was removed from kidney and pancreas allocation system in the United States on March 15, 2021 in favor of a distance based policy to provide geographic equity to access to transplantation. The policy change was introduced at a time when ongoing Coronavirus Disease 2019 (COVID‐19) pandemic cases were declining following the first delta wave. Methods In this Scientific Registry of Transplant Recipients based study, deceased donor kidney transplant recipients between March 15 and December 2 of 2019, 2020 and 2021 were compared representing pre‐policy change, pre‐COVID cohort; pre‐policy change, early COVID cohort; and post‐policy change, late COVID cohort. Results There were 11336, 11808, and 12914 kidney transplants in the 2019, 2020, and 2021 cohorts, respectively. Proportion of kidney transplants increased from 8798 (78%) to 9496 (80%) to 11152 (86%), and decreased from 2538 (22%) to 2312 (20%) to 1762 (14%) within and beyond 250 nautical miles in subsequent years. Median distance between donor and transplant hospital increased (73 vs. 63 vs. 119 nautical miles, P < .001) and mean cold ischemia time increased (18.1 vs. 17.8 vs. 19.9 h, P < .001). Access to transplantation did not change for various racial groups ( P = .07), pediatric patients ( P = .29), dialysis vintage of >5 years ( P = .21), veterans ( P = .07) and decreased for those with calculated PRA of 99% and 100% ( P < .001). Rate of kidney discard (19.6% vs. 20.4% vs. 24%) remained high. Although there were numerical increases in transplants from donors with donation after circulatory death, donor acute kidney injury, kidney donor profile index >85% and donor age >60 years in successive years, rates of kidney discard also increased proportionally. Conclusion Improvement in the access to transplantation following the policy change was attenuated by the concurrent prevalence of the COVID‐19 pandemic.