How do highly sensitized patients get kidney transplants in the United States? Trends over the last decade

Abstract

Prioritization of highly sensitized (HS) candidates under the kidney allocation system (KAS) and growth of large, multicenter kidney-paired donation (KPD) clearinghouses have broadened the transplant modalities available to HS candidates. To quantify temporal trends in utilization of these modalities, we used SRTR data from 2009 to 2017 to study 39 907 adult HS (cPRA ≥ 80%) waitlisted candidates and 19 003 recipients. We used competing risks regression to quantify temporal trends in likelihood of DDKT, KPD, and non-KPD LDKT for HS candidates (Era 1: January 1, 2009-December 31, 2011; Era 2: January 1, 2012-December 3, 2014; Era 3: December 4, 2014-December 31, 2017). Although the likelihood of DDKT and KPD increased over time for all HS candidates (adjusted subhazard ratio [aSHR] Era 3 vs 1 for DDKT: _1.74 1.85_1.97 , P < .001 and for KPD: _1.70 2.20_2.84 , P < .001), the likelihood of non-KPD LDKT decreased (aSHR: _0.69 0.82_0.97 , P = .02). However, these changes affected HS recipients differently based on cPRA. Among recipients, more cPRA 98%-99.9% and 99.9%+ recipients underwent DDKT (96.2% in Era 3% vs 59.1% in Era 1 for cPRA 99.9%+), whereas fewer underwent non-KPD LDKT (1.9% vs 30.9%) or KPD (2.0% vs 10.0%). Although KAS increased DDKT likelihood for the most HS candidates, it also decreased the use of non-KPD LDKT to transplant cPRA 98%+ candidates.

Keywords: clinical research/practice; donors and donation: deceased; donors and donation: paired exchange; health services and outcomes research; kidney transplantation/nephrology; panel reactive antibody (PRA); registry/registry analysis.

FIGURE 1

Outcomes of highly sensitized candidates by era and cPRA category. cPRA, calculated panel reactive antibody; DDKT, deceased donor kidney transplant; KPD, kidney-paired donation; LDKT, living donor kidney transplant; KAS, kidney allocation system. Era 1: January 1, 2009-December 31, 2011; Era 2: January 1, 2012-December 3, 2014; Era 3: December 4, 2014-December 31, 2017. Each figure shows the crude cumulative incidence of each potential waitlist outcome at 3-y after entering the DDKT waitlist by cPRA group (rows) and Era (columns) [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 2

Trends in highly sensitized (HS) recipient transplant modalities used by era and calculated panel reactive antibody (cPRA) category. Each figure (A-E) shows the annual percentage of HS recipients in each cPRA category that used each transplant modality. For example, 30.9% of cPRA 99.9%+ recipients underwent non-kidney-paired donation (KPD) living donor kidney transplant (LDKT) in Era 1, which decreased to 20.1% in Era 2, and then to 1.9% in Era 3. DDKT, deceased donor kidney transplant [Color figure can be viewed at wileyonlinelibrary.com]