Modest rates and wide variation in timely access to repeat kidney transplantation in the United States

Abstract

Success of transplantation is not limited to initial receipt of a donor organ. Many kidney transplant recipients experience graft loss following initial transplantation and the benefits of expedited placement on the waiting list and retransplantation extend to this population. Factors associated with access to repeat transplantation may be unique given experience with the transplant process and prior viability as a candidate. We examined the incidence, risk factors, secular changes, and center‐level variation of preemptive relisting or transplantation (PRLT) for kidney transplant recipients in the United States with graft failure (not due to death) using Scientific Registry of Transplant Recipients data from 2007 to 2018 (n = 39 557). Overall incidence of PRLT was 15% and rates of relisting declined over time. Significantly lower PRLT was evident among patients who were African American and Hispanic, males, older, obese, publicly insured, had lower educational attainment, were diabetic, had longer dialysis time prior to initial transplant, shorter graft survival, longer distance to transplant center, and resided in distressed communities. There was significant variation in PRLT by center, median = 13%, 10th percentile = 6%, 90th percentile = 24%. Cumulatively, results indicate that despite prior access to transplantation, incidence of PRLT is modest with pronounced clinical, social, and center‐level sources of variation suggesting opportunities to improve preemptive care among patients with failing grafts.

Effects of body mass index on kidney transplant outcomes are significantly modified by patient characteristics

“…Selected obese patients gain a survival advantage with kidney transplantation relative to maintenance dialysis in almost all subsets of the population, but specific transplant eligibility criteria based on BMI thresholds may vary between transplant centers 12 . Relative to patients with BMI classified in normal ranges, obese patients have significantly diminished access to kidney transplantation 13‐17 . Transplant centers may also advise obese patients to lose weight prior to considering their eligibility for the procedure 18,19 …”

Risk Factors Influencing the Outcomes of Kidney Re-Transplantation

“…The alternative to repeat transplantation is dialysis. As known from the literature, first transplantation as well as re-transplantation are both clearly better than dialysis; therefore, even preemptive second transplantation has been proposed [ 43 – 45 ]. The relative risk reduction by transplantation seems to be higher in re-transplanted patients because of their higher mortality on the waiting list [ 10 ].…”

Racial disparities in preemptive waitlisting and deceased donor kidney transplantation: Ethics and solutions

“…Clinician bias could also explain the disconcerting racial disparity in preemptive re‐transplantation—that is, a patient with a failing kidney transplant getting a repeat transplant without requiring dialysis. This disparity is surprising because prior kidney transplant recipients by definition have relationships with transplant centers and previously navigated the evaluation process successfully 18 …”