The kidney allocation system and pediatric transplantation at 5 years

Abstract

Background A new Kidney Allocation System (KAS) was implemented in the United States in 2014 with the goal of improving equity and utility. Methods In this study, we compare outcomes for kidney‐alone candidates less than 18 years of age, at the time of listing, in the 5 years prior to and following policy implementation using Organ Procurement and Transplantation Network data. Results While the pediatric deceased donor transplant rate increased under KAS, this increase was due solely to improved access for children aged 11–17 years; there was an 18.9% decrease in the deceased donor transplant rate among children 0–5 years old, from 117.94 to 95.8 transplants per 100 person‐years (p = .001). The cumulative incidence of deceased donor transplantation by 1 year after listing decreased from 39.3% in the pre‐KAS era to 35.5% in the post‐KAS era (p = .004), a decline that was driven entirely by longer wait times for children 0–5 years old (p = .017). Candidates with a calculated panel reactive antibody of 98%–100% experienced a significant increase in transplant rate, but there was no change in transplant rate for Black or Hispanic candidates. Conclusion Overall, KAS increased transplantation access for teenaged and highly sensitized candidates but resulted in decreased access for the youngest children with no improvement in racial/ethnic equality.

Predicting wait time for pediatric kidney transplant: a novel index

“…This does not align with previous findings showing significant increases in the rate of transplantation for highly sensitized patients with elevated cPRA values, an intended result by the 2014 KAS update [ 35 – 39 ]. Previous literature has also shown a resultant significant decline in rate of transplantation for those with lower cPRA values, primarily those with a value of zero percent [ 38 , 39 ]. Our findings are likely due to priority points being assigned to patients with increasing cPRA values, counterbalanced by the difficulty in finding a donor that has minimal to no reactive antigens [ 26 ].…”

Unrecognized opportunities: The landscape of pediatric kidney‐paired donation in the United States

“…All recipients were followed until June 2022 (i.e., a minimum of 6 months of post‐transplant follow‐up) using the December 2022 SRTR standard analysis file. To align with KAS' definition of pediatric recipients, 21 inclusion criteria for the study defined pediatric kidney recipients as those who were < 18 years from birth on the day of the transplant. We excluded multi‐organ transplants.…”

Kidney paired donation

“…Analysis of current transplant policy shows decreased access to DDKT for children. Since the enactment of the 2014 Kidney Allocation System (KAS), wait times for DDKT increased, and DDKT rates decreased for young children 1,2 . Current policy remains in flux as we move towards a continuous distribution model for organ allocation; a system aimed at eliminating geographic boundaries and instead using a composite allocation score 3 .…”

“…Since the enactment of the 2014 Kidney Allocation System (KAS), wait times for DDKT increased, and DDKT rates decreased for young children. 1,2 Current policy remains in flux as we move towards a continuous distribution model for organ allocation; a system aimed at eliminating geographic boundaries and instead using a composite allocation score. 3 The pediatric nephrology community remains diligent in advocating for pediatric priority, yet pediatric status in final scoring has yet to be determined and how this new scoring system will impact access remains to be seen.…”