Association of ESKD With Decreased Kidney Transplant Rates With US Kidney Allocation Policy | Health Disparities | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Association of High Burden of End-stage Kidney Disease With Decreased Kidney Transplant Rates With the Updated US Kidney Allocation Policy

Educational Objective
To identify the extent to which the new US kidney allocation policy will alter kidney transplant rates across the country.
1 Credit CME
Key Points

Question  Will the introduction of the new kidney allocation policy initiated by the Organ Procurement and Transplantation Network (OPTN) be equally beneficial to all areas of the US when considering the regional burden of end-stage kidney disease (ESKD)?

Findings  This economic evaluation of 122 659 patients with ESKD found that this policy change on kidney allocation using transplant rates normalized to the population with ESKD will result in disproportionate distribution of organs across the US.

Meaning  These findings suggest that states with lowest transplant rates among the population with ESKD will not benefit from these changes by the OPTN, and some may experience a decrease in allocated organs.

Abstract

Importance  The Organ Procurement and Transplantation Network (OPTN) approved changes to the US kidney allocation system in 2019. The potential effects of this policy change using transplant rates normalized to end-stage kidney disease (ESKD) incidence have not been investigated.

Objective  To estimate how the OPTN kidney allocation policy will affect areas of the US currently demonstrating low rates of kidney transplant, when accounting for the regional burden of ESKD.

Design, Setting, and Participants  This cross-sectional population-based economic evaluation analyzed access of patients with ESKD to kidney transplant in the US. Participants included patients with incident ESKD, those on the kidney transplant wait list, and those who received a kidney transplant. Data were collected from January 1 to December 31, 2017, and were analyzed in 2019.

Main Outcomes and Measures  The probability of a patient with ESKD being placed on the transplant wait list or receiving a deceased donor kidney transplant. States and donor service areas (DSAs) were compared for gains and losses in rates of transplanted kidneys under the new allocation system. Transplant rates were normalized for ESKD burden.

Results  A total of 122 659 patients had incident ESKD in the US in 2017 (58.2% men; mean [SD] age, 62.8 [15.1] years). The probability of a patient with ESKD receiving a deceased donor kidney transplant varied 3-fold across the US (from 6.36% in West Virginia to 18.68% in the District of Columbia). Modeling of the OPTN demonstrates that DSAs from New York (124%), Georgia (65%), and Illinois (56%) are estimated to experience the largest increases in deceased donor kidney allocation. Other than Georgia, these states have kidney transplant rates per incident ESKD cases above the mean (of 50 states plus the District of Columbia, New York is 16th and Illinois is 24th). In contrast, DSAs from Nevada (−74%), Ohio (−67%), and North Carolina (−61%)—each of which has a transplant rate per incident ESKD cases significantly below the mean—are estimated to experience the largest decreases in deceased donor allocation (of 50 states plus the District of Columbia, North Carolina is 34th, Ohio is 38th, and Nevada is 47th).

Conclusions and Relevance  The new OPTN-approved kidney allocation policy may result in worsening geographic disparities in access to transplants when measured against the burden of ESKD within a particular region of the US.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Accepted for Publication: February 13, 2021.

Published Online: May 26, 2021. doi:10.1001/jamasurg.2021.1489

Corresponding Author: Derek A. DuBay, MD, Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas St, 409 Room C1 Clinical Science Building, Charleston, SC 29425 (dubay@musc.edu).

Author Contributions: Dr DuBay was the principal investigator. Dr DuBay had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: DuBay, Mauldin, Weeda, Baliga, Taber.
Acquisition, analysis, or interpretation of data: DuBay, Morinelli, Su, Weeda, Casey, Taber.
Drafting of the manuscript: DuBay, Morinelli, Su, Taber.
Critical revision of the manuscript for important intellectual content: DuBay, Su, Mauldin, Weeda, Casey, Baliga, Taber.
Statistical analysis: DuBay, Su.
Administrative, technical, or material support: Morinelli, Taber.
Supervision: DuBay, Casey, Baliga.

Conflict of Interest Disclosures: Dr Casey reported receiving grants from Dialysis Clinic, Inc, outside the submitted work. No other disclosures were reported.

Disclaimer: The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the US government.

Additional Information: The data reported herein are publicly available from the US Census Bureau (https://www.census.gov/newsroom/press-kits/2018/pop-estimates-national-state.html), the Scientific Registry of Transplant Recipients (https://www.srtr.org/reports/program-specific-reports/), and the United States Renal Data System (https://www.usrds.org).

References
1.
Electronic Code of Federal Regulations: part 121—Organ Procurement and Transplantation network. Updated April 15, 2021. Accessed October 20, 2020. https://www.ecfr.gov/cgi-bin/text-idx?node=pt42.1.121&rgn=div5
2.
Davis  AE , Mehrotra  S , McElroy  LM ,  et al.  The extent and predictors of waiting time geographic disparity in kidney transplantation in the United States.   Transplantation. 2014;97(10):1049-1057. doi:10.1097/01.tp.0000438623.89310.dcPubMedGoogle ScholarCrossref
3.
Lynch  RJ , Patzer  RE .  Geographic inequity in transplant access.   Curr Opin Organ Transplant. 2019;24(3):337-342. doi:10.1097/MOT.0000000000000643PubMedGoogle ScholarCrossref
4.
Davis  AE , Mehrotra  S , Ladner  DP , Kilambi  V , Friedewald  JJ .  Changes in geographic disparity in kidney transplantation since the final rule.   Transplantation. 2014;98(9):931-936. doi:10.1097/TP.0000000000000446PubMedGoogle ScholarCrossref
5.
Melanson  TA , Hockenberry  JM , Plantinga  L ,  et al.  New kidney allocation system associated with increased rates of transplants among Black and Hispanic patients.   Health Aff (Millwood). 2017;36(6):1078-1085. doi:10.1377/hlthaff.2016.1625PubMedGoogle ScholarCrossref
6.
Zhang  X , Melanson  TA , Plantinga  LC ,  et al.  Racial/ethnic disparities in waitlisting for deceased donor kidney transplantation 1 year after implementation of the new national kidney allocation system.   Am J Transplant. 2018;18(8):1936-1946. doi:10.1111/ajt.14748PubMedGoogle ScholarCrossref
7.
Stewart  DE , Wilk  AR , Toll  AE ,  et al.  Measuring and monitoring equity in access to deceased donor kidney transplantation.   Am J Transplant. 2018;18(8):1924-1935. doi:10.1111/ajt.14922PubMedGoogle ScholarCrossref
8.
King  KL , Husain  SA , Mohan  S .  Geographic variation in the availability of deceased donor kidneys per wait-listed candidate in the United States.   Kidney Int Rep. 2019;4(11):1630-1633. doi:10.1016/j.ekir.2019.08.018PubMedGoogle ScholarCrossref
9.
Hanaway  MJ , MacLennan  PA , Locke  JE .  Exacerbating racial disparities in kidney transplant: the consequences of geographic redistribution.   JAMA Surg. 2020;155(8):679-681. doi:10.1001/jamasurg.2020.1455PubMedGoogle ScholarCrossref
10.
OPTN/UNOS Ad Hoc Geography Committee. Frameworks for Organ Distribution. Briefing paper. Published December 4, 2018. Accessed October 27, 2020. https://optn.transplant.hrsa.gov/media/2762/geography_boardreport_201812.pdf
11.
Saran  R , Robinson  B , Abbott  KC ,  et al.  US Renal Data System 2018 USRDS annual data report: epidemiology of kidney disease in the United States.   Am J Kidney Dis. 2019;73(3 suppl 1):A7-A8. doi:10.1053j.ajkd.2019.01.001Google Scholar
12.
Scientific Registry of Transplant Recipients. Organ Procurement Organization (OPO) reports. Published 2019. Accessed March 26, 2020. https://www.srtr.org/reports-tools/opo-specific-reports/
13.
Organ Procurement and Transplant Network. Eliminate the use of DSA and region in kidney allocation policy. Published December 2019. Accessed March 26, 2020. https://optn.transplant.hrsa.gov/governance/public-comment/eliminate-the-use-of-dsa-and-region-in-kidney-allocation-policy/
14.
Scientific Registry of Transplant Recipients. Program-specific reports on organ transplants. Published 2019. Accessed September 7, 2020. https://www.srtr.org/reports/program-specific-reports/
15.
Reed  RD , Shelton  BA , Mustian  MN , MacLennan  PA , Sawinski  D , Locke  JE .  Geographic differences in population health and expected organ supply in the Gulf Coast region of the United States compared to non-Gulf states.   Transplantation. 2020;104(2):421-427. doi:10.1097/TP.0000000000002831 PubMedGoogle ScholarCrossref
16.
Davis  AE , Mehrotra  S , Kilambi  V ,  et al.  The effect of the statewide sharing variance on geographic disparity in kidney transplantation in the United States.   Clin J Am Soc Nephrol. 2014;9(8):1449-1460. doi:10.2215/CJN.05350513PubMedGoogle ScholarCrossref
17.
Laupacis  A , Keown  P , Pus  N ,  et al.  A study of the quality of life and cost-utility of renal transplantation.   Kidney Int. 1996;50(1):235-242. doi:10.1038/ki.1996.307PubMedGoogle ScholarCrossref
18.
Wolfe  RA , Ashby  VB , Milford  EL ,  et al.  Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant.   N Engl J Med. 1999;341(23):1725-1730. doi:10.1056/NEJM199912023412303PubMedGoogle ScholarCrossref
19.
United Network for Organ Sharing. UNOS fast facts. Published 2020. Accessed October 28, 2020. https://unos.org/about/fast-facts/
21.
McPherson  LJ , Barry  V , Yackley  J ,  et al; Southeastern Kidney Transplant Coalition.  Distance to kidney transplant center and access to early steps in the kidney transplantation process in the Southeastern United States.   Clin J Am Soc Nephrol. 2020;15(4):539-549. doi:10.2215/CJN.08530719PubMedGoogle ScholarCrossref
22.
Hamoda  RE , McPherson  LJ , Lipford  K ,  et al.  Association of sociocultural factors with initiation of the kidney transplant evaluation process.   Am J Transplant. 2020;20(1):190-203. doi:10.1111/ajt.15526PubMedGoogle ScholarCrossref
23.
Patzer  RE , McPherson  L , Wang  Z ,  et al.  Dialysis facility referral and start of evaluation for kidney transplantation among patients treated with dialysis in the Southeastern United States.   Am J Transplant. 2020;20(8):2113-2125. doi:10.1111/ajt.15791Google ScholarCrossref
24.
Scientific Registry of Transplant Recipients. For transplant center professionals. Published 2020. Accessed October 21, 2020. https://www.srtr.org/faqs/for-transplant-center-professionals/
25.
Scientific Registry of Transplant Recipients. SRTR program-specific report: kidney. Released January 7, 2019. Accessed January 5, 2020. https://www.srtr.org/document/pdf?fileName=%5C012019_release%5CpdfPSR%5CSCMUTX1KI201811PNEW.pdf
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close