Referral and Evaluation for Kidney Transplantation Following Implementation of the 2014 National Kidney Allocation System

Patzer, Rachel E.; Di, Mengyu; Zhang, Rebecca; McPherson, Laura; DuBay, Derek A.; Ellis, Matthew J.; Wolf, Joshua H.; Jones, Heather L.; Zayas, Carlos; Mulloy, Laura L.; Reeves‐Daniel, Amber; Mohan, Sumit; Perez, Aubriana; Trivedi, Amal N.; Pastan, Stephen O.

doi:10.1053/j.ajkd.2022.01.423

Cited by 11 publications

(8 citation statements)

References 27 publications

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“…One example is the change to the Kidney Allocation Score in 2014 which allowed transplant activation time to start from dialysis start date. This allowed for greater equity in access to transplantation for patients who did not have predialysis transplant access [83 ▪ ]. Similarly, a policy change in 2021 advocating for use of a race-free eGFR calculation allows for equitable access to kidney transplant for Black individuals [84].…”

Section: Potential Solutionsmentioning

confidence: 99%

Barriers to home dialysis and kidney transplantation for socially disadvantaged individuals

Rizzolo,

Shen

2023

Current Opinion in Nephrology &Amp; Hypertension

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Purpose of review People with kidney disease facing social disadvantage have multiple barriers to quality kidney care. The aim of this review is to summarize the patient, clinician, and system wide factors that impact access to quality kidney care and discuss potential solutions to improve outcomes for socially disadvantaged people with kidney disease. Recent findings Patient level factors such as poverty, insurance, and employment affect access to care, and low health literacy and kidney disease awareness can affect engagement with care. Clinician level factors include lack of early nephrology referral, limited education of clinicians in home dialysis and transplantation, and poor patient-physician communication. System-level factors such as lack of predialysis care and adequate health insurance can affect timely access to care. Neighborhood level socioeconomic factors, and lack of inclusion of these factors into public policy payment models, can affect ability to access care. Moreover, the effects of structural racism and discrimination nay negatively affect the kidney care experience for racially and ethnically minoritized individuals. Summary Patient, clinician, and system level factors affect access to and engagement in quality kidney care. Multilevel solutions are critical to achieving equitable care for all affected by kidney disease.

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Section: Potential Solutionsmentioning

confidence: 99%

Barriers to home dialysis and kidney transplantation for socially disadvantaged individuals

Rizzolo,

Shen

2023

Current Opinion in Nephrology &Amp; Hypertension

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“…This policy change was expected to reduce racial differences in kidney transplantation access given the substantial racial differences in time from kidney failure diagnosis to waitlisting 5 ; early results suggest that the policy reduced racial disparities in transplant among those patients who were already referred, evaluated, and successfully waitlisted. 6 However, because the policy was expected to have a large effect on patients with longer dialysis times, it was critical to ensure that clinical providers who educate and refer patients to transplant were aware of KAS implications for dialysis patients.…”

Section: Introductionmentioning

confidence: 99%

The ASCENT Intervention to Improve Access and Reduce Racial Inequalities in Kidney Waitlisting

Patzer

Zhang

Buford

et al. 2023

CJASN

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Background The US kidney allocation system (KAS) changed in 2014, but dialysis facility staff (including nephrologists, social workers, nurse managers, and facility administrators) had low awareness of how this policy change could affect their patients' access to transplant. We assessed the effectiveness of a multicomponent and multilevel educational and outreach intervention targeting US dialysis facilities with low waitlisting, with a goal of increasing waitlisting and reducing Black versus White racial disparities in waitlisting. MethodsThe Allocation System Changes for Equity in Kidney Transplantation (ASCENT) study was a clusterrandomized, pragmatic, multilevel, effectiveness-implementation trial including 655 US dialysis facilities with low waitlisting, randomized to receive either the ASCENT intervention (a performance feedback report, a webinar, and staff and patient educational videos) or an educational brochure. Absolute and relative differences in coprimary outcomes (1-year waitlisting and racial differences in waitlisting) were reported among incident and prevalent patients.Results Among 56,332 prevalent patients, 1-year waitlisting decreased for patients in control facilities (2.72%-2.56%) and remained the same for patients in intervention facilities (2.68%-2.75%). However, the proportion of prevalent Black patients waitlisted in the ASCENT interventions increased from baseline to 1 year (2.52%-2.78%), whereas it remained the same for White patients in the ASCENT intervention facilities (2.66%-2.69%). Among incident patients in ASCENT facilities, 1-year waitlisting increased among Black patients (from 0.87% to 1.07%) but declined among White patients (from 1.54% to 1.27%). Significant racial disparities in waitlisting were observed at baseline, with incident Black patients in ASCENT facilities less likely to waitlist compared with White patients (adjusted odds ratio [aOR], 0.56; 95% confidence interval [CI], 0.35 to 0.92), but 1 year after the intervention, this racial disparity was attenuated (aOR, 0.84; 95% CI, 0.49 to 1.42). ConclusionsThe ASCENT intervention may have a small effect on extending the reach of the new KAS policy by attenuating racial disparities in waitlisting among a population of US dialysis facilities with low waitlisting.

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“…Whereas waiting time accumulation previously began on the date of waitlisting, KAS aimed to reduce adverse consequences of late referral by initiating waiting time credit at the date of dialysis initiation rather than at the date the patient was later waitlisted. However, both before and after this change, patients belonging to disadvantaged demographic and economic groups, including patients with minority race, low educational attainment, and low socioeconomic status, have lower rates of transplant referral, waitlisting, transplants overall, transplants before dialysis initiation, and living donor transplants …”

Section: Introductionmentioning

confidence: 99%

“…However, both before and after this change, patients belonging to disadvantaged demographic and economic groups, including patients with minority race, low educational attainment, and low socioeconomic status, have lower rates of transplant referral, waitlisting, transplants overall, transplants before dialysis initiation, and living donor transplants. [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] Understanding the magnitude of underwaitlisting and waitlisting disparities is challenging due to difficulty determining the denominator of potentially waitlist-eligible patients. Given that a combination of advanced age and significant medical comorbidities may preclude transplantation or minimize its benefit, the cohort of all patients receiving dialysis includes some for whom transplant is not appropriate.…”

mentioning

confidence: 99%

Disparities in Kidney Transplant Waitlisting Among Young Patients Without Medical Comorbidities

Husain,

Yu,

King

et al. 2023

JAMA Intern Med

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ImportanceDisparities in kidney transplant referral and waitlisting contribute to disparities in kidney disease outcomes. Whether these differences are rooted in population differences in comorbidity burden is unclear.ObjectiveTo examine whether disparities in kidney transplant waitlisting were present among a young, relatively healthy cohort of patients unlikely to have medical contraindications to kidney transplant.Design, Setting, and ParticipantsThis retrospective cohort study used the US Renal Data System Registry to identify patients with end-stage kidney disease who initiated dialysis between January 1, 2005, and December 31, 2019. Patients who were older than 40 years, received a preemptive transplant, were preemptively waitlisted, or had documented medical comorbidities other than hypertension or smoking were excluded, yielding an analytic cohort of 52 902 patients. Data were analyzed between March 1, 2022, and February 1, 2023.Main Outcome(s) and Measure(s)Kidney transplant waitlisting after dialysis initiation.ResultsOf 52 902 patients (mean [SD] age, 31 [5] years; 31 132 [59%] male; 3547 [7%] Asian/Pacific Islander, 20 782 [39%] Black/African American, and 28 006 [53%] White) included in the analysis, 15 840 (30%) were waitlisted for a kidney transplant within 1 year of dialysis initiation, 11 122 (21%) were waitlisted between 1 and 5 years after dialysis initiation, and 25 940 (49%) were not waitlisted by 5 years. Patients waitlisted within 1 year of dialysis initiation were more likely to be male, to be White, to be employed full time, and to have had predialysis nephrology care. There were large state-level differences in the proportion of patients waitlisted within 1 year (median, 33%; range, 15%-58%). In competing risk regression, female sex (adjusted subhazard ratio [SHR], 0.92; 95% CI, 0.90-0.94), Hispanic ethnicity (SHR, 0.77; 95% CI, 0.75-0.80), and Black race (SHR, 0.66; 95% CI, 0.64-0.68) were all associated with lower waitlisting after dialysis initiation. Unemployment (SHR, 0.47; 95% CI, 0.45-0.48) and part-time employment (SHR, 0.74; 95% CI, 0.70-0.77) were associated with lower waitlisting compared with full-time employment, and more than 1 year of predialysis nephrology care, compared with none, was associated with greater waitlisting (SHR, 1.51; 95% CI, 1.46-1.56).Conclusions and RelevanceThis retrospective cohort study found that fewer than one-third of patients without major medical comorbidities were waitlisted for a kidney transplant within 1 year of dialysis initiation, with sociodemographic disparities in waitlisting even in this cohort of young, relatively healthy patients unlikely to have a medical contraindication to transplantation. Transplant policy changes are needed to increase transparency and address structural barriers to waitlist access.

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Referral and Evaluation for Kidney Transplantation Following Implementation of the 2014 National Kidney Allocation System

Cited by 11 publications

References 27 publications

Barriers to home dialysis and kidney transplantation for socially disadvantaged individuals

Barriers to home dialysis and kidney transplantation for socially disadvantaged individuals

The ASCENT Intervention to Improve Access and Reduce Racial Inequalities in Kidney Waitlisting

Disparities in Kidney Transplant Waitlisting Among Young Patients Without Medical Comorbidities

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