Trends in Disparities in Preemptive Kidney Transplantation in the United States

Abstract

Background and objectives: Long wait times for deceased donor kidneys and low rates of preemptive wait-listing have limited preemptive transplantation in the United States. We aimed to assess trends in preemptive deceased donor transplantation with the introduction of the new Kidney Allocation System (KAS) in 2014 and identify whether key disparities in preemptive transplantation have changed.

Design, setting, participants, & measurements: We identified adult deceased donor kidney transplant recipients in the United States from 2000 to 2018 using the Scientific Registry of Transplant Recipients. Preemptive transplantation was defined as no dialysis before transplant. Associations between recipient, donor, transplant, and policy era characteristics and preemptive transplantation were calculated using logistic regression. To test for modification by KAS policy era, an interaction term between policy era and each characteristic of interest was introduced in bivariate and adjusted models.

Results: The proportion of preemptive transplants increased after implementation of KAS from 9.0% to 9.8%, with 1.10 (95% confidence interval [95% CI], 1.06 to 1.14) times higher odds of preemptive transplantation post-KAS compared with pre-KAS. Preemptive recipients were more likely to be white, older, female, more educated, hold private insurance, and have ESKD cause other than diabetes or hypertension. Policy era significantly modified the association between preemptive transplantation and race, age, insurance status, and Human Leukocyte Antigen zero-mismatch (interaction P<0.05). Medicare patients had a significantly lower odds of preemptive transplantation relative to private insurance holders (pre-KAS adjusted OR, [aOR] 0.26; [95% CI, 0.25 to 0.27], to 0.20 [95% CI, 0.18 to 0.22] post-KAS). Black and Hispanic patients experienced a similar phenomenon (aOR 0.48 [95% CI, 0.45 to 0.51] to 0.41 [95% CI, 0.37 to 0.45] and 0.43 [95% CI, 0.40 to 0.47] to 0.40 [95% CI, 0.36 to 0.46] respectively) compared with white patients.

Conclusions: Although the proportion of deceased donor kidney transplants performed preemptively increased slightly after KAS, disparities in preemptive kidney transplantation persisted after the 2014 KAS policy changes and were exacerbated for racial minorities and Medicare patients.

Keywords: European Continental Ancestry Group; HLA antigens; Hispanic Americans; Insurance Coverage; Medicare; Registries; United States; adult; allocation system; chronic kidney failure; deceased donor; diabetes mellitus; female; health policy; humans; hypertension; kidney failure, chronic; kidney transplantation; logistic models; preemptive kidney transplantation; renal dialysis; tissue donors; transplant recipients; unintended consequences.

Graphical abstract

Figure 1.

Flow chart for selecting the study population. SPK, simultaneous pancreas-kidney; SRTR, Scientific Registry of Transplant Recipients; tx, transplant.

Figure 2.

Proportions of deceased donor kidney transplants occurring preemptively over time, by race/ethnicity and primary insurance payer. *2018 data only available through May 31, 2018. KAS, Kidney Allocation System.

Figure 3.

ORs for unadjusted associations with preemptive deceased donor transplantation pre-KAS (2000–2013) and post-KAS (2015–2018). KAS, Kidney Allocation System; PCKD, polycystic kidney disease.