Failure to Advance Access to Kidney Transplantation over Two Decades in the United States

Abstract

Background: Extensive research and policies have been developed to improve access to kidney transplantation among patients with ESKD. Despite this, wide variation in transplant referral rates exists between dialysis facilities.

Methods: To evaluate the longitudinal pattern of access to kidney transplantation over the past two decades, we conducted a retrospective cohort study of adult patients with ESKD initiating ESKD or placed on a transplant waiting list from 1997 to 2016 in the United States Renal Data System. We used cumulative incidence models accounting for competing risks and multivariable Cox models to evaluate time to waiting list placement or transplantation (WLT) from ESKD onset.

Results: Among the study population of 1,309,998 adult patients, cumulative 4-year WLT was 29.7%, which was unchanged over five eras. Preemptive WLT (prior to dialysis) increased by era (5.2% in 1997-2000 to 9.8% in 2013-2016), as did 4-year WLT incidence among patients aged 60-70 (13.4% in 1997-2000 to 19.8% in 2013-2016). Four-year WLT incidence diminished among patients aged 18-39 (55.8%-48.8%). Incidence of WLT was substantially lower among patients in lower-income communities, with no improvement over time. Likelihood of WLT after dialysis significantly declined over time (adjusted hazard ratio, 0.80; 95% confidence interval, 0.79 to 0.82) in 2013-2016 relative to 1997-2000.

Conclusions: Despite wide recognition, policy reforms, and extensive research, rates of WLT following ESKD onset did not seem to improve in more than two decades and were consistently reduced among vulnerable populations. Improving access to transplantation may require more substantial interventions.

Keywords: end-stage renal disease; kidney transplantation; risk factors.

Graphical abstract

Figure 1.

Proportion of adult patients 18–70 years placed on the waiting list or transplanted within 1 year of ESKD. Patients placed on the waiting list either prior to or within 1 year of ESKD onset.

Figure 2.

Cumulative incidence of wait list placement or transplant by era onset. Competing risk model with inception point minimum of ESKD onset date or placement on the transplant waiting list, with death a competing risk (censored at last follow-up).

Figure 3.

Cumulative incidence of mortality prior to wait list placement or transplantation by era from time of ESKD. Competing risk model with inception point at ESKD onset date and WLT a competing risk (censored at last follow-up).

Figure 4.

Cumulative incidence of 4-year wait list placement or transplantation by median zip code level household income and era. Competing risk model with inception point minimum of ESKD onset date or placement on the transplant waiting list with death a competing risk (censored at last follow-up). Median household income estimated from patients’ primary residential zip code and the American Community Surveys from 2000, 2008, and 2016.

Figure 5.

Cumulative incidence of 4-year wait list placement or transplantation and adjusted hazards for time to wait list placement or transplantation among patients in 2013–2016 by ESKD network. Darker shade indicates higher adjusted hazard ratio for wait list placement of transplantation. Ref, reference ESKD network.