Impact Of Kidney Allocation System Research Articles

Referral and Evaluation for Kidney Transplantation Following Implementation of the 2014 National Kidney Allocation System

The national kidney allocation system (KAS) implemented in December 2014 in the United States redefined the start of waiting time from the time of waitlisting to the time of kidney failure. Waitlisting has declined post-KAS, but it is unknown if this is due to transplant center practices or changes in dialysis facility referral and evaluation. The purpose of this study was to assess the impact of the 2014 KAS policy change on referral and evaluation for transplantation among a population of incident and prevalent patients with kidney failure. Cohort study. 37,676 incident (2012-2016) patients in Georgia, North Carolina, and South Carolina identified within the US Renal Data System at 9 transplant centers and followed through December 2017. A prevalent population of 6,079 patients from the same centers receiving maintenance dialysis in 2012 but not referred for transplantation in2012. KAS era (pre-KAS vs post-KAS). Referral for transplantation, start of transplant evaluation, and waitlisting. Multivariable time-dependent Cox models for the incident and prevalent population. Among incident patients, KAS was associated with increased referrals (adjusted HR, 1.16 [95% CI, 1.12-1.20]) and evaluation starts among those referred (adjusted HR, 1.16 [95% CI, 1.10-1.21]), decreased overall waitlisting (adjusted HR, 0.70 [95% CI, 0.65-0.76]), and lower rates of active waitlisting among those evaluated compared to the pre-KAS era (adjusted HR, 0.81 [95% CI, 0.74-0.90]). Among the prevalent population, KAS was associated with increases in overall waitlisting (adjusted HR, 1.74 [95% CI, 1.15-2.63]) and active waitlisting among those evaluated (adjusted HR, 2.01 [95% CI, 1.16-3.49]), but had no significant impact on referral or evaluation starts among those referred. Limited to 3 states, residual confounding. In the southeastern United States, the impact of KAS on steps to transplantation was different among incident and prevalent patients with kidney failure. Dialysis facilities referred more incident patients and transplant centers evaluated more incident patients after implementation of KAS, but fewer evaluated patients were placed onto the waitlist. Changes in dialysis facility and transplant center behaviors after KAS implementation may have influenced the observed changes in access to transplantation.

Evolving Trends in Racial Disparities for Peri-Operative Outcomes with the New Kidney Allocation System (KAS) Implementation.

To improve kidney transplant allocation equitability, a new Kidney Allocation System (KAS) was implemented December 4, 2014. The purpose of this study was to determine if the impact of KAS on peri-operative outcomes differed by recipient race/ethnicity. This was a time series analysis using data aggregated in monthly intervals from October 2012 through September 2015 using the University HealthSystem Consortium (UHC). This includes national data aggregated at the center level of all US kidney transplant centers that participate in the UHC (416 centers). Segmented regression with interaction terms was used to determine the impact of KAS on outcomes and differences by race/ethnicity. A total of 28,809 deceased donor kidney transplants were included with 25months of pre-KAS data and 10months of post-KAS data. After KAS implementation, the estimated transplant rate per month decreased significantly for Caucasians by 17.6 cases per month (p = 0.0001), and increased significantly for AAs by 37.8 (p = 0.0001), Hispanics by 16.3 (p = 0.0001), and other races by 8.2 cases per month (p = 0.0001). Delayed graft function, 7- and 14-day readmissions significantly increased after KAS, which did not differ by race. Hispanics saw a 7.7% decrease in ICU admissions after KAS, which differed as compared to other racial/ethnic cohorts (p = 0.0026). Costs of kidney transplantation increased significantly after KAS in all groups except Hispanics. Mortality, length of stay, in-hospital complications, and 30-day readmissions were not significantly impacted by KAS, also not differing by race/ethnicity. KAS had substantial impact on transplant rates by race/ethnicity. KAS also led to increased costs, readmissions, and delayed graft function (DGF) across all racial/ethnic groups. The impact of KAS on ICU cases solely within Hispanics requires further investigation into potential etiologies.

P003 Impact of the new kidney allocation system on the transplant rates of highly sensitized patients. A single center experience

Aim Increasing transplant opportunities for difficult-to-match patients was a primary goal of the new kidney allocation system (KAS) implemented on Dec 4, 2014. In this study, we evaluated the impact of KAS on the transplantation rate of sensitized candidates at our center. Methods During Jan 1–Dec 4, 2014 (pre-KAS interval) and Jan 1–Dec 4, 2015 (post-KAS interval), unacceptable HLA antigens for kidney transplant candidates were reported to UNET using the following cutoffs: 5000 MFI for HLA-A, -B and -DR, and 10,000 MFI for HLA-C and -DQ antigens. Deceased donor crossmatches (XMs) were performed by flow cytometry and complement dependent cytotoxicity (CDC). Patients were transplanted based on a negative flow and/or negative CDC XM. Results A total of 613 and 1188 deceased donor XMs were performed during pre- and post-KAS intervals, respectively. The number of XMs performed for sensitized patients (cPRA>0%) increased from 116 (19%) XMs performed pre-KAS to 309 (26%) post-KAS (p 98%, 50–79% and 1–49% (Table 1). During pre- and post-KAS intervals, a total of 115 and 129 patients, respectively, received deceased donor kidney transplantation at our center. As indicated in Table 1, the number of sensitized recipients increased from 16 (14% of pre-KAS transplants) to 32 (25% of post-KAS transplants). The highest increase was seen in patients with cPRA>98% (from 0% to 8%). Transplant outcomes were analyzed in the non-sensitized (N = 97) and sensitized (N = 32) patient groups, who received deceased donor kidney allografts post-KAS. Graft survival, patient survival, creatinine levels and incidence of acute rejection were similar in the two groups. Conclusion The new KAS facilitated a marked increase in the transplant rate of sensitized candidates at our center. The HLA laboratory played a key role in achieving this goal by providing thorough testing and ensuring safe transplantation of difficult-to-match patients. Download : Download high-res image (140KB) Download : Download full-size image