Clinical Context

There have been clear disparities in the distribution of kidney transplants for decades, and it is sad but not surprising that race and ethnicity have played a role in these disparities. Black and Hispanic patients have historically been less likely than White patients to receive a kidney transplant, but how much does the higher burden of comorbid illness among Black and Hispanic patients contribute to this difference? A previous study by Ku and colleagues, published in the July 2020 issue of Transplantation, evaluated this issue.^[1]

Study data were drawn from patients registered between 2005 and 2014 in the US Renal Data System, which collects information on patients with end-stage kidney disease (ESKD). Researchers included 986,019 patients who initiated dialysis. Almost 65,000 renal transplants occurred during a mean of 2.3 years of follow-up.

In this cohort, the rate of medical barriers to transplantation was actually lower among Black and Hispanic patients compared with among non-Hispanic White patients. However, access to transplant in the first year of dialysis was 65% and 43% lower for Black and Hispanic patients vs for non-Hispanic White patients. These disparities had resolved by year 4 of follow-up.

There was a disparity favoring non-Hispanic White patients for kidney transplant in the planned analysis of all adults with a low rate of risk factors for transplant. Moreover, the disparity against Black and Hispanic patients was more persistent. In this subgroup analysis, non-Hispanic White patients remained more likely than Black and Hispanic patients to receive a kidney transplant through years 4 or 5 of follow-up.

Previous efforts have attempted to reduce disparities in access to kidney transplant, including both racial and geographic disparities. The current analysis focuses on the potential effects of efforts in 2019 by the Organ Procurement and Transplantation Network (OPTN) to reduce geographic variability in access to kidney transplant.

Study Synopsis and Perspective

The introduction of the new kidney allocation policy in the US initiated by the OPTN may not benefit all states equally when the regional burden of ESKD is taken into account, a new cross-sectional, population-based economic evaluation suggests.

The analysis shows that the probability of a patient with ESKD receiving a deceased donor kidney transplant varied 3-fold across the United States in 2017, with the lowest probability being in West Virginia, at 6.4%, and the highest likelihood being in the District of Columbia, at 18.7%.

"The rationale for the [OPTN] allocation changes was that the calculated waiting time for a deceased donor kidney transplant differed by more than 5 years, depending on the geographic location of the transplant center for a patient on the wait list," lead author Derek DuBay, MD, from the Medical University of South Carolina, Charleston, and colleagues observe.

"Our analysis demonstrates that states with the lowest transplant rates normalized for ESKD burden will not benefit from the changes by the OPTN, and several are projected to experience significant decreases in kidney organ allocation volume," they add.

The study was published online May 26 in JAMA Surgery.^[2]

The new OPTN policy was approved in late 2019 and became effective March 15, 2021. The updated policy on matching kidney and pancreas transplant candidates with organs from deceased donors replaces distribution based on donation service area (DSA) and OPTN region. The new policy means that kidneys and pancreases will be first offered to candidates listed at transplant hospitals within 250 nautical miles of the donor hospital. Offers not accepted for any of these candidates will then be made for candidates beyond the 250-nautical-mile distance.

For their study, Dr DuBay and colleagues used a merged data set from the US Renal Disease System plus data from the Scientific Registry of Transplant Recipients.

The population included patients with ESKD as well as those who had undergone kidney transplantation during 2017. A total of 122,659 new patients with ESKD were included in the analysis, 35,447 of whom were added to the kidney transplant waitlist during that year.

"Marked differences were found in ESKD incidence across the US; the highest rates are in the District of Columbia, the Southeast, West Virginia, and New Jersey," Dr DuBay and colleagues point out. The lowest incidence rates of ESKD were found in the Mountain West states, Minnesota, and some New England states.

Similarly, the likelihood of a new patient with ESKD being added to the transplant waitlist varied significantly across the United States. Patients most likely to be waitlisted were in Wyoming, Colorado, Minnesota, and several New England states.

In contrast, the lowest probabilities of a new patient with ESKD being waitlisted were in Hawaii, Oregon, Nevada, Oklahoma, Arkansas, Louisiana, and Ohio River Valley states.

Most important, there were "stark differences" in the probability of a new patient with ESKD actually receiving a living or deceased donor transplant across the United States, with again a greater than 3-fold difference in the probability of patients receiving any type of donor transplant, with those in Hawaii, at 9.16%, being the least likely, and those in Utah being the most likely, at 31.16%.

As the authors explain, the modeling method used by the OPTN to determine deceased donor allocation is based on DSAs, the nonprofit agencies that coordinate deceased donation.

"Based on kidney transplant frequency...one might expect with the new OPTN allocation system that Hawaii, West Virginia, Arkansas, Mississippi, and Nevada should receive the largest increase in deceased donor kidneys," the authors note.

This turns out not to be the case, however, because DSAs from New York, Georgia, and Illinois are more likely to have the biggest increase in deceased donor allocation, they observe.

With the exception of Georgia, "these states with increased kidney allocation have transplant rates above the mean (of 50 states plus the District of Columbia)."

OPTN modeling also suggests that DSAs from Nevada, Ohio, and North Carolina are at the most risk of experiencing the largest decrease in deceased donor allocations, yet these same states have transplant rates below the mean of 50 states plus the District of Columbia.

In fact, New York City is expected to have the largest increase in deceased donor kidneys, at 124%, versus the state of Nevada, which is expected to see a 74% decrease in deceased donor kidneys based on the new OPTN modeling changes. 

"We strongly believe the best method to assess for organ allocation equity and geographic disparities is to estimate the proportion of patients with ESKD who receive a transplant," the authors argue.

"Regrettably, ESKD burden is completely ignored in the changes approved by the OPTN to the kidney allocation system in late 2019.... Until the playing field is level, it is important for the OPTN to not create policies that potentially worsen disparities in access to transplant," they emphasize.

Commenting on the findings, Kenneth Andreoni, MD, from the University of Florida, Gainesville, pointed out that the "real goal" of any national organ allocation policy should be to increase the availability of deceased donor transplants for all eligible candidates.

Paradoxically, this might be one of the few "silver linings" to emerge from the COVID-19 pandemic.

"After the declaration of a national public health emergency on March 13, 2020, the Scientific Registry of Transplant Recipients stated that they would not follow up recipient outcome after this date," Dr Andreoni explained.

Freedom from this standard "punitive" regulation through program-specific reports was likely responsible for 2020 being a record year for transplant volume, he pointed out, despite having fewer living donor transplants, the pandemic burden on transplantation hospitals, and the risk for potential transplant recipients becoming infected with COVID-19. "The COVID-19 pandemic has allowed the real-life experiment to take place," Dr Andreoni observed.

"Removal of the threat of the program-specific reports has allowed the transplantation community to offer more lifesaving transplants to US recipients, despite the unprecedented healthcare stresses in 2020," he underscored.

Dr DuBay and Dr Andreoni have reported no relevant financial relationships.

JAMA Surg. Published online May 26, 2021.

Clinical Implications

• This previous study found that kidney transplant was delayed in the first year of dialysis for Black and Hispanic patients compared with for non-Hispanic White patients. By year 4, these disparities had resolved, but they did persist in the subgroup of adults who had few risk factors for complications after transplant.
• The current study suggests that policies adopted by the OPTN in 2019 may actually worsen geographic disparities in kidney transplant.
• Implications for the healthcare team: The healthcare team should understand the local, state, and federal dynamics of organ procurement and kidney transplant to best advocate for their patients.

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