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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)?
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.
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.
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.
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.
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.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
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 (email@example.com).
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).
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