Patients with High Priority for Kidney Transplant Who Are Not Given Expedited Placement on the Transplant Waiting List Represent Lost Opportunities
Authors: Schold Jesse D. , Huml Anne M. , Poggio Emilio D. , Sedor John R. , Husain Syed A. , King Kristin L. , Mohan Sumit 
Published: June 2021

Significance Statement
The deceased donor Kidney Allocation System prioritizes transplant candidates with top 20% Estimated Post-Transplant Survival (EPTS) scores (signifying longest expected survival post-transplantation) to receive optimal deceased donor kidneys. An analysisof United States Renal Data System data found that fewer than half of eligible patients with ESKD with top 20% EPTS scores were placed on the transplant waiting list. Nonlisted patients were disproportionally Black, lacked commercial insurance, and resided in lower-income communities. Many patients, particularly those initiating dialysis before waitlist placement, lose EPTS status over time, narrowing the window to receive an optimal deceased donor kidney on the basis of top EPTS status. These findings highlight the existence of barriers to transplant among some patients with excellent prognoses, and a need for efforts to expedite their access to transplantation.

Background
Kidney 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.

Methods
We 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.

Results
Of 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.

Conclusions
Many 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.

Podcast
This article contains a podcast athttps://www.asn-online.org/media/podcast/JASN/2021_07_30_JASN2020081146.mp3