Kidney • Dialysis • Organ transplantation
Following the implementation of the 2014 kidney allocation system (KAS), dialysis facilities referred more incident patients and transplant centers evaluated more incident patients, but fewer evaluated patients were placed on the waitlist, according to a study of patients starting dialysis between 2012 and 2016. Following the adoption of the 2014 KAS, changes in dialysis facility and transplant center conduct may have altered transplantation access.
Following the introduction of the 2014 modification in the kidney allocation method, waitlisting has decreased throughout the country (KAS). The goal of this study, led by Dr. Rachel Patzer of Emory University, was to see if the decrease in waitlisting was due to lower referral, evaluation, or waitlisting rates in the Southeastern United States, which is the only region with systematic data collection on early transplant steps that would allow for this analysis. The results from this area, which includes Georgia, North Carolina, and South Carolina, reveal that KAS reduced overall waitlisting among the incident population that began the review process.
Following the installation of KAS, dialysis facilities sent more incident patients and transplant centers examined more incident patients, but fewer evaluated patients were put on the waitlist. Overall, the impact of KAS varied by transplant step and by incident vs. prevalent dialysis patients, and decreases in waitlisting documented in the post-KAS period are mostly related to lower waitlisting of referred patients at transplant centers.
“We’ve observed a decrease in waitlisting throughout the country, which is an unanticipated effect of this policy shift. Because patients are not collecting time on the list based on the date they were put on the list, there is less need to waitlist them early “In an email to Medscape Medical News, Rachel Patzer, PhD, MPH, of Emory University School of Medicine in Atlanta, Georgia, said:
On December 4, 2014, a new kidney allocation system (KAS) was established after more than a decade of debate, study, and consensus-building. Improved lifetime matching between donor kidneys and recipients was a key aim, as was expanding access for previously disadvantaged subpopulations, such as highly sensitive patients and individuals who had been on dialysis for a long time but were not referred for transplantation. To assess KAS’s early effect, we analyzed data from the Organ Procurement and Transplantation Network one year before and after its adoption. The distribution of transplants over a wide range of recipient characteristics has shifted dramatically, indicating that the new strategy is meeting its objectives in many respects. Transplants in which the donor and recipient were more than 30 years apart dropped by 23%. Initially, there was a substantial rise in transplants for Calculated Panel-Reactive Antibody 99-100 percent patients and recipients who had been on dialysis for at least 10 years, with a later tapering of transplants to these groups, indicating bolus effects. Although KAS seems to have improved allocation fairness, the consequences of increasing access must be weighed. Kidneys are being transported over longer distances more often, resulting in longer cold ischemia periods. The incidence of delayed graft function has risen, while the 6-month graft survival rate has remained same.
Introduction
In December 2014, the United Network for Organ Sharing (UNOS) launched a new Kidney Allocation System (KAS) that is projected to significantly minimize racial inequalities in kidney transplantation among patients on the waiting list. However, not all dialysis facility clinical practitioners and patients with end-stage renal disease (ESRD) are aware of how the policy change may increase transplantation availability.
Methods
The ASCENT (Allocation System Changes for Equity in Kidney Transplantation) study is a randomized, controlled effectiveness-implementation study that aims to see if a multicomponent intervention can improve access to the early stages of kidney transplantation in dialysis centers across the United States. An instructional webinar for dialysis medical directors, an educational film for patients and an educational video for dialysis personnel, and a dialysis facility-specific transplantation performance feedback report are all part of the multicomponent intervention. A multidisciplinary dissemination advisory group will produce the materials, which will go through formative testing in dialysis centers throughout the country.
Results
This research is expected to recruit 600 dialysis clinics in the United States with minimal waitlists across all 18 ESRD networks. Changes in waitlisting and waitlist disparity at one year are co-primary outcomes; secondary outcomes include changes in facility medical director knowledge of KAS, staff training on KAS, patient education on transplantation, and the medical director’s intent to refer patients for transplantation evaluation.
Discussion
The ASCENT study’s findings will show the feasibility and efficacy of a multicomponent intervention aimed at increasing access to the deceased donor kidney waitlist and reducing racial inequalities in waitlisting.
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