Impact of the Kidney Transplantation Moratorium in France Because of the COVID-19 Pandemic: A Cohort-based Study

Abstract

Background: The COVID-19 pandemic has resulted in worldwide kidney transplantation (KT) moratoriums. The impacts of these moratoriums on the life expectancy of KT candidates remain unclear.

Methods: We simulated the evolution of several French candidate populations for KT using a multistate semi-Markovian approach and according to moratorium durations ranging from 0 to 24 mo. The transition rates were modeled from the 63 927 French patients who began dialysis or were registered on the waiting list for KT between 2011 and 2019.

Results: Among the 8350 patients active on the waiting list at the time of the French KT moratorium decided on March 16, 2020, for 2.5 mo, we predicted 4.0 additional months (confidence interval [CI], 2.8-5.0) on the waiting list and 42 additional deaths (CI, -70 to 150) up to March 16, 2030, compared with the scenario without moratorium. In this population, we reported a significant impact for a 9-mo moratorium duration: 135 attributable deaths (CI, 31-257) up to March 16, 2030. Patients who became active on the list after March 2020 were less impacted; there was a significant impact for an 18-mo moratorium (175 additional deaths [CI, 21-359]) in the 10 862 prevalent end-stage renal disease patients on March 16, 2020 and for a 24-mo moratorium (189 additional deaths [CI, 10-367]) in the 16 355 incident end-stage renal disease patients after this date.

Conclusion: The temporary moratorium of KT during a COVID-19 peak represents a sustainable decision to free up hospitals' resources if the moratorium does not exceed a prolonged period.

FIGURE 1.

Multistate natural history of end-stage renal disease from entry into the REIN registry (CKD). Patients who started a dialysis while being registered on the waitlist at inclusion were considered beginning a dialysis first and being registered on the waitlist afterward. CKD, chronic kidney disease; REIN, Renal Epidemiology and Information Network.

FIGURE 2.

Impact of the KT moratorium on active patients on the waiting list in March 2020 (n = 8350). A‚ Overall patient survival. B‚ Cumulative probability of death and transplantation. C‚ Decrease in the 5-y life expectancy according to several moratorium durations compared with the scenario with no moratorium. D‚ Additional months on the waiting list up to 5 y according to several moratorium durations compared with the scenario with no moratorium. KT, kidney transplantation; RMST, restricted mean survival time; RMWL, restricted mean survival time on the waiting list.

FIGURE 3.

Impact of the KT moratorium on nonactive patients on the waiting list in March 2020 who will become active before March 2025 (n = 10 862). A‚ Overall patient survival. B‚ Cumulative probability of death and transplantation. C‚ Decrease in the 5-y life expectancy according to several moratorium durations compared with the scenario with no moratorium. D‚ Additional months on the waiting list up to 5 y according to several moratorium durations compared with the scenario with no moratorium. KT, kidney transplantation; RMST, restricted mean survival time; RMWL, restricted mean survival time on the waiting list.

FIGURE 4.

Impact of KT moratorium on incident patients in the REIN registry after March 2020 who will become active before March 2025 (n = 16 355). A‚ Overall patient survival. B‚ Cumulative probability of death and transplantation. C‚ Decrease in the 5-y life expectancy according to several moratorium durations compared with the scenario with no moratorium. D‚ Additional months on the waiting list up to 5 y according to several moratorium durations compared with the scenario with no moratorium. KT, kidney transplantation; REIN, Renal Epidemiology and Information Network; RMST, restricted mean survival time; RMWL, restricted mean survival time on the waiting list.