COVID-19 and Access to Kidney Transplantation for Older Candidates in the United States: A National Registry Study

Abstract

Rationale & ObjectiveCOVID-19 has likely impacted accessibility to transplantation services among older adults (age ≥65). We quantified the impact of COVID-19 on kidney transplantation access for older kidney-only candidates registered on the US kidney waitlist. Study DesignRetrospective analysis of registry data Setting & Participants57,222 older adults who were part of or added to the US kidney waitlist between 1/1/2016-2/28/2022, identified using the Scientific Registry of Transplant Recipients (SRTR). ExposuresFour COVID-19 waves and one non-wave period based on the national incidence of COVID-19 in the United States (Initial: 3/15/20-5/31/20; winter 2020-21: 12/1/20-1/31/21; delta: 8/1/21-9/30; omicron: 12/1/21-2/28/22; non-wave: inter-wave periods) OutcomesWaitlist registrations, deceased-donor kidney transplants, living-donor kidney transplants, waitlist mortality, and waitlist removals due to deteriorating condition (hereafter referred to as removals) Analytical ApproachPoisson regression for the adjusted incidence rate ratio (aIRR) of each outcome during the COVID-19 waves and the non-wave period relative to reference [1/1/16-12/31/19], adjusted for seasonality and secular trends. ResultsWaitlist registrations initially declined, and increased henceforth. Deceased donor kidney transplants and living donor kidney transplants remained below expected during all waves. Waitlist mortality peaked during the winter 2020-21 wave (aIRR: 1.701.982.30) and has declined since; mortality rates were 139%, 107%, and 251% above expected for Black candidates, men, and candidates aged ≥75 years, respectively, during the winter 2020-21 wave. Removals increased from 22% below expected (initial wave) to 26% above expected (omicron wave); removals were non-significantly higher than expected during the omicron wave for older Black and Hispanic candidates. LimitationsThe findings are not generalizable to those listed at earlier ages with prolonged waitlist times. Additionally, using national COVID-19 incidence doesn’t consider local policy and healthcare variations. Lastly, aIRRs must be interpreted cautiously due to smaller daily event counts. ConclusionsCOVID-19 was associated with fewer transplants, and increased mortality and removals in older kidney transplant candidates. Transplant providers should consider this impact and implement policies and practices to ensure the continuity of care.