Changes in offer and acceptance patterns for pediatric kidney transplant candidates under the new Kidney Allocation System

Jackson, Kyle R.; Bowring, Mary G.; Kernodle, Amber; Boyarsky, Brian J.; Desai, Niraj M.; Charnaya, Olga; Garonzik-Wang, Jacqueline M; Massie, Allan B.; Segev, Dorry L.

doi:10.1111/ajt.15799

Cited by 12 publications

(17 citation statements)

References 22 publications

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“…This latter prioritization is particularly notable given the rapid rise in the frequency of multi‐organ transplantation and the fact that these kidneys are often of very high quality, raising important questions of whether they are consistent with principles of maximal utilization 12,13 . As a result of these features, the implementation of KAS has been found to be associated with inferior wait‐list outcomes for pediatric candidates, including longer pretransplant dialysis time, decreased access to kidneys from pediatric donors, and decreased likelihood of transplant for the youngest pediatric candidates 14–18 . Our data further show that pediatric candidates with prior transplants are often not transplanted in a timely manner under KAS, leaving them susceptible to the permanent consequences of impaired growth and neuropsychiatric development 3–5 .…”

Section: Discussionmentioning

confidence: 65%

“…12,13 As a result of these features, the implementation of KAS has been found to be associated with inferior wait-list outcomes for pediatric candidates, including longer pretransplant dialysis time, decreased access to kidneys from pediatric donors, and decreased likelihood of transplant for the youngest pediatric candidates. [14][15][16][17][18] Our data further show that pediatric candidates with prior transplants are often not transplanted in a timely manner under KAS, leaving them susceptible to the permanent consequences of impaired growth and neuropsychiatric development. [3][4][5] Expediting transplant for this vulnerable group of candidates will therefore likely require changes in the allocation system to create a greater advantage for pediatric candidates to avoid the deleterious impact of delayed transplant.…”

Section: Discussionmentioning

confidence: 67%

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Access to kidney transplantation among pediatric candidates with prior solid organ transplants in the United States

Husain

King

Owen‐Simon

et al. 2022

Pediatric Transplantation

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Kidney transplantation provides numerous important benefits compared with dialysis for children with end-stage kidney disease. In addition to improved survival, transplantation is associated with better quality of life, linear growth, pubertal development and neuropsychiatric development compared with maintenance dialysis. [1][2][3][4][5][6] Given these time-sensitive benefits during a key developmental period, kidney allocation in the United States has historically prioritized expedited transplantation for wait-listed pediatric candidates.

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Section: Discussionmentioning

confidence: 65%

Section: Discussionmentioning

confidence: 67%

Access to kidney transplantation among pediatric candidates with prior solid organ transplants in the United States

Husain

King

Owen‐Simon

et al. 2022

Pediatric Transplantation

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“…However, the new allocation strategy may have disfavored very young children awaiting deceased donor kidneys. [26][27][28] It is too soon for us to demonstrate an effect of these changes on long-term survival.…”

Section: Discussionmentioning

confidence: 99%

Transplantation Mediates Much of the Racial Disparity in Survival from Childhood-Onset Kidney Failure

Becerra

Chan

Eggers

et al. 2022

JASN

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Background: The role of kidney transplantation in differential survival in Black and White patients with childhood-onset kidney failure is unexplored. Methods: We analyzed 30-year cohort data of children beginning renal replacement therapy (RRT) before age 18 between January 1980 and December 2017 (n=28,337) in the U.S. Renal Data System. Cox regression identified transplant factors associated with survival by race. The survival mediational g-formula estimated the excess mortality among Black patients that could be eliminated if an intervention equalized their time with a transplant to that of White patients. Results: Black children comprised 24% of the cohort and their crude 30-year survival was 39% compared to 57% for White children (log rank p<0.001). Black children had 45% higher risk of death (adjusted hazard ratio (aHR) 1.45, 95% confidence interval (CI) 1.36, 1.54) and 31% lower incidence of first transplant (aHR 0.69, 95% CI 0.67, 0.72), and 39% lower incidence of second transplant (aHR 0.61, CI 0.57, 0.65). Children and young adults are likely to require multiple transplants, yet even after their first transplant, Black patients had 11% fewer total transplants (adjusted incidence rate ratio (aIRR) 0.89, 95% CI 0.86, 0.92). In Black patients grafts failed earlier after first and second transplants. Overall,Black patients spent 24% less of their RRT time with a transplant than did White patients (aIRR 0.76, 95% CI 0.74, 0.78). Transplantation compared with dialysis strongly protected against death (aHR 0.28, 95% CI 0.16, 0.48) by timevarying analysis. Mediation analyses estimated that equalizing transplant duration could prevent 35% (p<.001) of excess deaths in Black patients. Conclusions: Equalizing time with a functioning transplant for Black patients may equalize survival of childhood-onset ESRD with White patients.

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“…Since the implementation of KAS in 2014, pediatric transplant can- (p = .03), 11 attributing the decline in transplant rate to a decline in acceptance. Post-KAS the declined kidneys were significantly more likely to be from donors at increased risk of disease transmission and over 35 years of age, suggesting that pediatric transplant centers may be declining offers that have morbidity risks that are not captured by KDPI.…”

Section: Discussionmentioning

confidence: 99%

“…The cause of this decline is not clear. Jackson et al investigated deceased donor kidney acceptance patterns for pediatric candidates and reported a 23% decrease in acceptances of offers from donors aged 18–34 years old with a KDPI of <35% ( p = .03), 11 attributing the decline in transplant rate to a decline in acceptance. Post‐KAS the declined kidneys were significantly more likely to be from donors at increased risk of disease transmission and over 35 years of age, suggesting that pediatric transplant centers may be declining offers that have morbidity risks that are not captured by KDPI.…”

Section: Discussionmentioning

confidence: 99%

The kidney allocation system and pediatric transplantation at 5 years

Engen

Smith

Bartosh

2022

Pediatric Transplantation

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Background A new Kidney Allocation System (KAS) was implemented in the United States in 2014 with the goal of improving equity and utility. Methods In this study, we compare outcomes for kidney‐alone candidates less than 18 years of age, at the time of listing, in the 5 years prior to and following policy implementation using Organ Procurement and Transplantation Network data. Results While the pediatric deceased donor transplant rate increased under KAS, this increase was due solely to improved access for children aged 11–17 years; there was an 18.9% decrease in the deceased donor transplant rate among children 0–5 years old, from 117.94 to 95.8 transplants per 100 person‐years (p = .001). The cumulative incidence of deceased donor transplantation by 1 year after listing decreased from 39.3% in the pre‐KAS era to 35.5% in the post‐KAS era (p = .004), a decline that was driven entirely by longer wait times for children 0–5 years old (p = .017). Candidates with a calculated panel reactive antibody of 98%–100% experienced a significant increase in transplant rate, but there was no change in transplant rate for Black or Hispanic candidates. Conclusion Overall, KAS increased transplantation access for teenaged and highly sensitized candidates but resulted in decreased access for the youngest children with no improvement in racial/ethnic equality.

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Changes in offer and acceptance patterns for pediatric kidney transplant candidates under the new Kidney Allocation System

Cited by 12 publications

References 22 publications

Access to kidney transplantation among pediatric candidates with prior solid organ transplants in the United States

Access to kidney transplantation among pediatric candidates with prior solid organ transplants in the United States

Transplantation Mediates Much of the Racial Disparity in Survival from Childhood-Onset Kidney Failure

The kidney allocation system and pediatric transplantation at 5 years

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