Early Changes in Kidney Distribution under the New Allocation System

Abstract

The Kidney Allocation System (KAS), a major change to deceased donor kidney allocation, was implemented in December 2014. Goals of KAS included directing the highest-quality organs to younger/healthier recipients and increasing access to deceased donor kidney transplantation (DDKT) for highly sensitized patients and racial/ethnic minorities. Using national registry data, we compared kidney distribution, DDKT rates for waitlist registrants, and recipient characteristics between January 1, 2013, and December 3, 2014 (pre-KAS) with those between December 4, 2014, and August 31, 2015 (post-KAS). Regional imports increased from 8.8% pre-KAS to 12.5% post-KAS; national imports increased from 12.7% pre-KAS to 19.1% post-KAS (P,0.001). The proportion of recipients .30 years older than their donor decreased from 19.4% to 15.0% (P,0.001). The proportion of recipients with calculated panelreactive antibody =100 increased from 1.0% to 10.3% (P,0.001). Overall DDKT rate did not change as modeled using exponential regression adjusting for candidate characteristics (P=0.07). However, DDKT rate (incidence rate ratio, 95% confidence interval) increased for black (1.19; 1.13 to 1.25) and Hispanic (1.13; 1.05 to 1.20) candidates and for candidates aged 18-40 (1.47; 1.38 to 1.57), but declined for candidates aged .50 (0.93; 0.87 to 0.98 for aged 51-60 and 0.90; 0.85 to 0.96 for aged .70). Delayed graft function in transplant recipients increased from 24.8% pre-KAS to 29.9% post-KAS (P,0.001). Thus, in the first 9 months under KAS, access to DDKT improved for minorities, younger candidates, and highly sensitized patients, but declined for older candidates. Delayed graft function increased substantially, possibly suggesting poorer long-term outcomes.

The weekend effect alters the procurement and discard rates of deceased donor kidneys in the United States

“…Both sub-analyses confirmed that the observed phenomena were not limited to only a part of the study period. Recent studies have also suggested that kidney discard is on the rise, following the introduction of the new kidney allocation system in the U.S. in 2014 (16). …”

Preemptive kidney transplantation is associated with survival benefits among pediatric patients with end-stage renal disease

“…Although the KAS policy has not created a statistically significant disadvantage to pediatric access to transplant so far, pediatric transplant rates do appear to be declining. 35 As organ demand continues to outpace supply, longer waiting times for children are likely inevitable unless policy modifications are adopted to specifically address minimizing pediatric dialysis exposure time.…”

32 Doses of Bortezomib for Desensitization Is Not Well Tolerated and Is Associated With Only Modest Reductions in Anti-HLA Antibody

“…This therapy may have been more effective in a less sensitized patient cohort, but the highly sensitized cohort we targeted is the most in need of therapy. National registry data shows that despite the new kidney allocation system in the United States, 6% of the patients on the deceased donor waitlist have a cPRA of 100% (1). These patients have the longest transplant waiting time and are subject to increased morbidity and mortality on dialysis.…”

“…Intense efforts to increase transplantation for these patients including kidney paired donation and priority for compatible deceased donor organs have been successful, but are not adequate. Currently, 6% of patients on the KTx waiting list have a cPRA of a 100 % (1). The current therapy available to decrease alloantibody is largely ineffective, and positive crossmatch kidney transplantation is associated with antibody mediated rejection and early allograft loss (2-11).…”