Reassessing Preemptive Kidney Transplantation in the United States

Abstract

BACKGROUND Preemptive kidney transplantation (preKT) is associated with higher patient survival, improved quality of life, and lower costs. However, only a minority of patients receives preKT. The aim of this study was to examine changes over the past decade in rates of preKT, focusing on living donor kidney transplantation (LDKT) and specifically recipients who underwent kidney transplantation within one year of initiating dialysis. METHODS Using United Network of Organ Sharing data, we examined retrospectively all kidney transplant candidates (n=369,103) and recipients (n=141,254) from 2003-2012 in the United States focusing on LDKT (n=47,108). Predictors of preKT were examined, and patient and graft survival were compared for preKT, pre-transplant dialysis < 1 year, and pre-transplant dialysis ≥ 1 year recipients. RESULTS PreKT occurred in only 17% of recipients overall and 31% of LDKT recipients. Medicare patients (OR=0.29, 95%CI=0.28-0.31), diabetics (OR=0.75, 95%CI=0.69-0.80), and minorities (Hispanics OR=0.62, 95%CI=0.57-0.68 & African-Americans OR=0.58, 95%CI=0.53-0.63) were less likely to receive preKT. Dialysis < 1 year recipients comprised 30% of non-preemptive LDKT. Dialysis < 1 year recipients had similar patient survival to preKT (5 yr: preKT 94%, dialysis < 1 yr 94%, & dialysis ≥ 1 yr 89%, p<0.01), but decreased death-censored graft survival (5 yr: preKT 93%, dialysis < 1 yr 89%, & dialysis ≥ 1 yr 89%, p<0.01). CONCLUSIONS PreKT remains an unrealized goal for the majority of recipients. Medicare patients, diabetics, and minorities are less likely to receive preKT. Almost one-third of non-preemptive LDKT recipients dialyze < 1 year, highlighting an important target for improvement.

Measuring Transplant Center Performance: the Goals Are Not Controversial but the Methods and Consequences Can Be

“…[14] This is a potential reflection of a loss of private contracts after a LP higher rates of LDKT among recipient with private insurance as the primary payer. [26, 27]…”

Modest rates and wide variation in timely access to repeat kidney transplantation in the United States

“…Studies have identified race and ethnicity, body mass index, health insurance, gender, age, community risk factors, and primary cause of kidney disease as factors associated with time to placement on a waiting list for transplantation . Many of these factors are also associated with preemptive transplantation, which continues to occur in a small minority of transplants in the United States . Factors that are associated with access to repeat transplantation may be unique as compared to patients without a prior transplant, given prior navigation of processes to acquire a transplant and prior qualification as a viable transplant candidate.…”

“…[7][8][9][10][11][12] Many of these factors are also associated with preemptive transplantation, which continues to occur in a small minority of transplants in the United States. 13,14 Factors that are associated with access to repeat transplantation may be unique as compared to patients without a prior transplant, given prior navigation of processes to acquire a transplant and prior qualification as a viable transplant candidate. In addition, the duration, complications, and reasons for graft failure from initial transplantation may predispose patients' willingness and viability for a repeat transplant.…”

Survival Benefit in Older Patients Associated With Earlier Transplant With High KDPI Kidneys

“…Currently, only 11% of deceased donor kidney transplants are performed preemptively, and only 2.5% of all patients with end-stage renal disease undergo preKT. 5,10,11 Non-ideal renal allografts, previously designated as extended criteria donor (ECD) kidneys, represent 1 opportunity for increasing access to earlier and potentially preemptive transplantation in older patients.…”