Patients with High Priority for Kidney Transplant Who Are Not Given Expedited Placement on the Transplant Waiting List Represent Lost Opportunities

ABSTRACTBackgroundKidney transplantation is associated with the best outcomes for most patients with ESKD. The national Kidney Allocation System prioritizes patients with Estimated Post-Transplant Survival (EPTS) scores in the top 20% for expedited access to optimal deceased donor kidneys.MethodsWe studied adults aged ≥18 years in the United States Renal Data System with top 20% EPTS scores who had been preemptively waitlisted or initiated dialysis in 2015–2017. We evaluated time to waitlist placement, transplantation, and mortality with unadjusted and multivariable survival models.ResultsOf 42,445 patients with top 20% EPTS scores (mean age, 38.0 years; 57% male; 59% White patients, and 31% Black patients), 7922 were preemptively waitlisted. Among 34,523 patients initiating dialysis, the 3-year cumulative waitlist placement incidence was 37%. Numerous factors independently associated with waitlisting included race, income, and having noncommercial insurance. For example, waitlisting was less likely for Black versus White patients, and for patients in the lowest-income neighborhoods versus those in the highest-income neighborhoods. Among patients initiating dialysis, 61% lost their top 20% EPTS status within 30 months versus 18% of patients who were preemptively listed. The 3-year incidence of deceased and living donor transplantation was 5% and 6%, respectively, for patients who initiated dialysis and 26% and 44%, respectively, for patients who were preemptively listed.ConclusionsMany patients with ESKDqualifying with top 20% EPTS status are not placed on the transplant waiting list in a timely manner, with significant variation on the basis of demographic and social factors. Patients who are preemptively listed are more likely to receive benefits of top 20% EPTS status. Efforts to expedite care for qualifying candidates are needed, and automated transplant referral for patients with the best prognoses should be considered.

Beyond CPRA: Identifying Sensitized Kidney Candidates with Markedly Low Access to Deceased Donor Transplantation by Granular CPRA and Blood Type

Prioritization in the US Kidney Allocation System (KAS) has led to an improvement in the rates of transplantation in highly sensitized (HS) patients. However, there is a subset of HS patients who are at a disadvantage, despite prioritization under KAS. The purpose of this study was to describe the transplant rate (TR) by calculated panel reactive antibody (CPRA) of HS candidates before and five years post-KAS to characterize their access to deceased donor transplants and quantify the number of HS candidates who are at a marked disadvantage in accessing kidneys. Using de-identified OPTN data, the number of solitary deceased donor kidney transplants performed (by month) from June 2013 through December 2019 was analyzed for four CPRA groups (95–97%, 98%, 99%, and 100%), with the CPRA 100% group further stratified into two subgroups (99.5–99.9% and >99.9%). The impact of the recipient blood group was assessed as an additional factor in TR. Immediately after KAS, TR rose 7-fold from 0.26% to 1.7% for the CPRA 99–100% group as a whole, and 12-fold and 8-fold for the CPRA 99.5–99.9% and CPRA 99.9%+ groups, respectively. However, the post-KAS mean TR of 0.63% for CPRA 99.9%+ candidates remained markedly lower than the mean TR of the other sensitized groups: 1.5% for CPRA 95–97%, 1.4% for CPRA 98%, 2.0% for CPRA 99%, and 3.5% for CPRA 99.5–99.9%; a statistically significant 6-fold advantage of the CPRA 99.5–99.9% group over CPRA 99.9%+ candidates was observed, despite both groups receiving national priority under KAS. Patients with a CPRA of 99.9%+ and blood group B were 2.16, 1.98, and 1.75 times less likely to receive a transplant compared to the same CPRA group with blood groups A, AB, and O, respectively, despite changes to KAS allocating blood type A2 and A2B to recipients with blood group B. Although the TR increased sharply for the CPRA 99.9%+ group with KAS, it remained markedly lower than the average despite national priority.

Failure of the New Kidney Allocation System in a Specific Ethnic Group

ABSTRACTIntroductionThe Kidney Allocation System (KAS) implemented on December 4, 2014, was expected to improve kidney transplant list wait-time and allocate more kidney to high cPRA patients. This study aims to demonstrate outcomes after the implementation of the KAS in a Hispanic transplant center.MethodsRetrospective study from a prospectively maintained database from a single-transplant center. Included all DDKT from July 2013 to June 2016. Compare and analyze DDKT selection and outcomes before and after KAS implementation.ResultsThe overall number of kidney transplants performed during this period was 220. All of the patients were Hispanic. Included 50.5% Pre-KAS and 49.5% Post-KAS. Pre-KAS group had a significantly shorter waiting-time list than the post-KAS group, 900.05 vs 1126.75 respectively. EPTS less than 20% significantly improved in the Post-KAS group compared to the Pre-KAS group, 41.3% vs 20.9% respectively. No differences observed in KDPI, 1-year graft failure, or 1-year mortality rates.ConclusionThis might be the first Hispanic only cohort evaluating the effects of KAS on a moderate volume kidney transplant center. The new system increased the wait-time list by approximately 25%, and it did not improve graft quality, graft failure, or mortality rates.

4354 The Impact of the 2014 Kidney Allocation System on Waitlisting Rates at the Dialysis Facility Level

OBJECTIVES/GOALS: The new Kidney Allocation System (KAS) was implemented in 2014 and it is not fully understood how its changes to patient incentives may have impacted dialysis facility waitlisting rates. We examine differences in facility performance and how such differences may have been impacted by this policy change. METHODS/STUDY POPULATION: We used Dialysis Facility Report data from 2011 to 2017 to study waitlisting rates at 3,392 dialysis facilities in the US, using waitlisting counts in the numerator, and the total number of ESRD patients in a facility as the denominator. We examined changes in waitlisting rates over by year at the facility, regional, and national level, and report national trends in waitlisting pre- and post-KAS. Facilities were stratified based on waitlisting rate in 2011 and then we examined whether each facility moved into a higher or lower quartile or stayed in the same quartile in 2017. RESULTS/ANTICIPATED RESULTS: Among n = 3,392 dialysis facilities, the average change in dialysis facility waitlisting rates from 2011 to 2017 was −4.74 percentage points (range -54.4% to 42.3%). Average change in dialysis facility waitlisting rates from 2011 to 2014 was −0.57 percentage points while the average change in dialysis facility waitlisting rates from 2014 to 2017 was −4.17 percentage points. Half of facilities in the 2011 lowest quartile remained in the lowest quartile in 2017; 45% of facilities in the top 2011 quartile dropped into a lower quartile. The middle 2 quartiles were fairly evenly split between worsening, improving, and not changing. DISCUSSION/SIGNIFICANCE OF IMPACT: Average waitlisting rates have declined since KAS implementation. Many facilities switched quartiles from 2011-17 suggesting that facility waitlisting rates are unstable over time. The decline in waitlisting rates post-KAS suggests that new allocation rules may be discouraging patients and/or providers from getting ESRD patients waitlisted.