Kidney Transplantation Needs Improvement for ESKD Patients

Jesse D. Schold, PhD

Despite effort and acknowledgement, new research shows kidney transplantation has not improved much in the last 2 decades for patients with end-stage kidney failure (EKSD).

A team, led by Jesse D. Schold, Department of Quantitative Health Sciences, Cleveland Clinic, evaluated the longitudinal patterns of access to kidney transplants over the course of the last 20 years for adult patients with end-stage kidney disease.

Two Decades of Challenges

In recent decades researchers have extensively researched and promoted different policies to improve access to kidney transplants for patients with end-stage kidney disease. However, there is still wide variation in transplant referral rates existing between different dialysis facilities.

The new retrospective cohort included adult patients with end-stage kidney disease initiating ESKD or placed on a transplant waiting list between 1997-2016 in the United States Renal Data System.

The researchers accounted for competing risks using cumulative incidence models and evaluated time to waiting list placement or transplantation (WLT) from ESKD onset using multivariable Cox models.

The study included 1.3 million adult patients in which the cumulative four-year WLT was 29.7%. This was unchanged over the course of 5 eras. The preemptive WLT prior to dialysis increased by era from 5.2% in 1997-2000 to 9.8% in 2013-2016.

A Lack of Improvements in Key Demographics

The four-year WLT incidence among patients between 60-70 years old also increased from 13.4% in 1997-2000 to 19.8% in 2013-2016.

The four-year WLT incidence diminished among patients between 18-39 years old during these eras, from 55.8% to 48.8%.

In addition, the incidence of WLT was significantly lower in patients from lower-income communities, with virtually no improvement over time.

The likelihood of WLT following dialysis substantially decreased over time (AHR, 0.80; 95% CI, 0.79-0.82) in 2013-2016 when compared to 1997-2000.

“Despite wide recognition, policy reforms, and extensive research, rates of WLT following ESKD onset did not seem to improve in more than two decades and were consistently reduced among vulnerable populations,” the authors wrote. “Improving access to transplantation may require more substantial interventions.”

A Push for More Transplants

Recently, new research based in the US showed the safety in the push to accept more transplant kidneys from hepatitis C viral (HCV) infected donors for hepatitis C negative recipients.

A team, led by Miklos Z. Molnar, MD, PhD, Associate Professor of Medicine, University of Tennessee Health Science Center James D. Eason Transplant Institute, examined the association of HCV infected donor status with kidney allograft function and post-transplant allograft biopsy findings.

The investigators noted that the HCV antibody positive donors trended towards being younger (median age, 35 years) in comparison with the HCV-negative donors (median age, 40 years).

Additionally, HCV positive donors had fewer comorbidities. For example, in the positive cohort, 8.3% had diabetes—versus 12.0% in the negative cohort (P<.001). Similarly, 25.9% of HCV-positive donors had hypertension, as did 35.2% of HCV-negative donors (P<.001).

Overall, there was not a statistically significant difference between the 2 groups in the delayed graft function rates (12% vs 8%), estimated GFRs post-transplant at 3, 6, 9 and 12 months, proportion of patients with cellular rejection (6% vs 7%), and proportion with antibody mediated rejection (7% vs 10%), or de novo DSAs (31% vs 20%).

The study, “Failure to Advance Access to Kidney Transplantation over Two Decades in the United States,” was published online in the Journal of the American Society of Nephrology.