Racial disparities in preemptive waitlisting and deceased donor kidney transplantation: Ethics and solutions

Abstract

Kidney transplantation prior to dialysis, known as “preemptive transplant,” enables patients to live longer and avoid the substantial quality of life burdens due to chronic dialysis. Deceased donor kidneys are a public resource that ought to provide health benefits equitably. Unfortunately, White, better educated, and privately insured patients enjoy disproportionate access to preemptive transplantation using deceased donor kidneys. This problem has persisted for decades and is exacerbated by the first-come, first-served approach to kidney allocation for predialysis patients. In this Personal Viewpoint, we describe the diverse barriers to preemptive waitlisting and kidney transplant. The analysis focuses on healthcare system features that particularly disadvantage Black patients, such as the waitlisting eligibility criterion of a single glomerular filtration rate or creatinine clearance ≤20 ml/min, and neglect of wide variation in the rate of progression to end-stage kidney disease (ESKD) in allocating preemptive transplants. We propose initiatives to improve equity including: (1) standardization of waitlisting eligibility criteria related to kidney function; (2) aggressive education for clinicians about early transplant referral; (3) innovations in electronic medical record capabilities; and (4) rapid status 7 listing by centers. If those initiatives fail, the transplant field should consider eliminating preemptive waitlisting and transplantation with deceased donor kidneys. Kidney transplantation prior to dialysis, known as “preemptive transplant,” enables patients to live longer and avoid the substantial quality of life burdens due to chronic dialysis. Deceased donor kidneys are a public resource that ought to provide health benefits equitably. Unfortunately, White, better educated, and privately insured patients enjoy disproportionate access to preemptive transplantation using deceased donor kidneys. This problem has persisted for decades and is exacerbated by the first-come, first-served approach to kidney allocation for predialysis patients. In this Personal Viewpoint, we describe the diverse barriers to preemptive waitlisting and kidney transplant. The analysis focuses on healthcare system features that particularly disadvantage Black patients, such as the waitlisting eligibility criterion of a single glomerular filtration rate or creatinine clearance ≤20 ml/min, and neglect of wide variation in the rate of progression to end-stage kidney disease (ESKD) in allocating preemptive transplants. We propose initiatives to improve equity including: (1) standardization of waitlisting eligibility criteria related to kidney function; (2) aggressive education for clinicians about early transplant referral; (3) innovations in electronic medical record capabilities; and (4) rapid status 7 listing by centers. If those initiatives fail, the transplant field should consider eliminating preemptive waitlisting and transplantation with deceased donor kidneys. Twenty years ago, Kasiske et al. reported that Black patients were much less likely to receive a preemptive kidney transplantation than White patients and recognized that “substantial efforts on the part of all who care for patients with kidney disease” would be required to correct this inequity.1Kasiske BL Snyder JJ Matas AJ Ellison MD Gill JS Kausz AT. Preemptive kidney transplantation: the advantage and the advantaged.J Am Soc Nephrol: JASN. 2002; 13: 1358-1364Crossref PubMed Scopus (0) Google Scholar,2Jay CL Dean PG Helmick RA Stegall MD. Reassessing Preemptive Kidney Transplantation in the United States: Are We Making Progress?.Transplantation. 2016; 100: 1120-1127Crossref PubMed Scopus (51) Google Scholar Yet, subsequent policy changes to the US kidney allocation system (KAS) that were implemented to mitigate transplant disparities have neglected preemptive kidney transplantation. In 2019, 11% of all adult deceased donor kidney transplants (1,859) were preemptive. White patients received 65% and Black patients received only 17% of those preemptive kidneys, during a year when the waiting list comprised 38% White and 31% Black patients. Figure 1 shows persistent racial disparities in preemptive kidney transplantation over time (Figure S1 shows geographic variation). Recently, King et al. analyzed national registry data and reported that, compared to White patients, Black patients had an adjusted Odds Ratio of 0.41 (95% CI 0.37, 0.45; p < .001) for receiving a preemptive deceased donor kidney transplant since implementation of the KAS in 2015—representing a widening disparity from the adjusted Odds Ratio of 0.48 prior to KAS.3King KL Husain SA Jin Z Brennan C Mohan S. Trends in Disparities in Preemptive Kidney Transplantation in the United States.Clin J Am Soc Nephrol. 2019; 14: 1500-1511Crossref PubMed Scopus (39) Google Scholar Although isolating the disadvantages associated with race can be complicated, the authors adjusted for characteristics relevant to time-to-transplantation including blood group and sensitization to human leukocyte antigen.3King KL Husain SA Jin Z Brennan C Mohan S. Trends in Disparities in Preemptive Kidney Transplantation in the United States.Clin J Am Soc Nephrol. 2019; 14: 1500-1511Crossref PubMed Scopus (39) Google Scholar It is important to recognize that preemptively waitlisted patients carry forward their allocation priority even after starting dialysis, so the major advantage of timely transplant referral is a key mechanism that facilitates inequities in access to the entire pool of deceased donor kidneys.4Organ Procurement and Transplantation Network. Policies. https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf. Accessed November 20, 2020.Google Scholar Figure 2 reveals major disparities in preemptive waitlisting over time. In 2019, 48% of waitlisted White patients, but only 22% of waitlisted Black patients, began to accrue waiting time priority before dialysis.FIGURE 2Racial disparities in preemptive waitlisting for kidney transplantation in the United States, over time. The proportion of all adult (age ≥18 years) candidates added to the kidney transplant waiting list in the United States between 1/1/2005 and 12/31/2019 who were listed preemptively (no dialysis start date reported) was calculated using the National UNOS STAR file based on OPTN data as of March 20, 2020 (see Methods Supplement)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Notably, King et al. also revealed substantially lower access to preemptive kidney transplantation among demographic groups expected to face challenges in navigating complex healthcare systems (e.g., patients with less than high school education) and more limited choice of physicians (e.g., Medicaid beneficiaries). In this Personal Viewpoint, however, we deliberately focus on Black patients because inequities in access to kidney transplantation are substantial and likely require multiple remedies. The goals of rationing organs are to maximize benefit and share that benefit equitably.5Veatch RM Ross LF. Transplantation Ethics. Georgetown University Press, Washington, D.C.2015Google Scholar The first-come, first-served approach that allows transplant priority to accrue for patients prior to starting dialysis is not well supported by the main concepts of equity.6Persad G Wertheimer A Emanuel EJ. Principles for allocation of scarce medical interventions.Lancet. 2009; 373: 423-431Abstract Full Text Full Text PDF PubMed Scopus (551) Google Scholar Aside from racial disparities, preemptive deceased donor kidney transplantation requires accepting that the clinical benefits for the fortunate individuals who avoid dialysis completely are sufficiently large to “offset” the equity problem that other patients endure many years of dialysis or die before transplantation. In some prominent ethical theories related to the fair distribution of scarce resources, preferences are given to the most disadvantaged individuals.6Persad G Wertheimer A Emanuel EJ. Principles for allocation of scarce medical interventions.Lancet. 2009; 373: 423-431Abstract Full Text Full Text PDF PubMed Scopus (551) Google Scholar,7Rawls J. A Theory of Justice. Harvard University Press, Cambridge, Massachusetts1971Crossref Google Scholar As a concrete manifestation of this approach to equity in kidney allocation, preference is given to children—who are highly disadvantaged because severe childhood illness exerts negative consequences across a lifetime.8Amaral S Reese PP. Children first in kidney allocation: the right thing to do.Transpl Int. 2014; 27: 530-532Crossref PubMed Scopus (7) Google Scholar With preemptive kidney transplantation, we see the opposite: already-advantaged patients with both residual kidney function and greater ability to navigate the health system—who are most likely to be White, better educated, and privately insured—get greater access. Viewed from this angle, the persistent status quo of racial and socioeconomic disparities in preemptive transplantation looks indefensible. Preemptive kidney transplantation improves health by avoiding dialysis and reducing the rate of early transplant complications. The transition to dialysis is associated with elevated death rates driven by fluctuations in blood pressure and volume status, inflammation, medication changes, and infections due to dialysis catheters. Preemptively waitlisted patients also enjoy the luxury of time before their kidney function deteriorates and may be able to pass up lower-quality organ offers. The median kidney donor profile index (KDPI) in 2019 was 39% for preemptive adult transplant recipients versus the KDPI of 45% for kidneys accepted by patients who received dialysis prior to transplant. While this difference in kidney quality is small, this finding is consistent with the idea that preemptively listed patients can afford to be selective in kidney acceptance. Preemptively listed patients may also get enhanced access to the best kidneys that are offered first to patients with the longest projected survival, because the survival projection algorithm (i.e., Estimated Posttransplant Survival [EPTS] score) favors patients with less dialysis time. As expected, only 9% of preemptive transplant recipients in 2019 had delayed graft function versus 31% of recipients transplanted after starting dialysis. Preemptive kidney transplantation recipients also enjoy reduced rates of and longer graft survival compared to those who receive deceased donor kidneys after starting BL Snyder JJ Matas AJ Ellison MD Gill JS Kausz AT. Preemptive kidney transplantation: the advantage and the advantaged.J Am Soc Nephrol: JASN. 2002; 13: 1358-1364Crossref PubMed Scopus (0) Google prior to donor kidney transplantation and rates of dialysis, transplantation: of the and PubMed Scopus (0) Google Scholar all the National Kidney preemptive transplant as the approach to J. National Kidney Preemptive Kidney Accessed 2020.Google Scholar Figure disparities in access to health the of waitlisting the of kidney allocation and in kidney disease progression across racial groups barriers to preemptive transplantation, particularly for Black In some referral to likely referral to transplant prior to dialysis and this problem is more severe for Black G et between race and geographic and in patients J Am Soc Nephrol. 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Principles for allocation of scarce medical interventions.Lancet. 2009; 373: 423-431Abstract Full Text Full Text PDF PubMed Scopus (551) Google Scholar some may that the we have from group to We that with and In the of rationing a resource such as deceased donor equity by access to a disadvantaged group access for individuals who benefit from preemptive kidney transplantation not those transplants more than Black patients or other disadvantaged The that the US system enables much rates of preemptive transplant and waitlisting for White, better educated, and privately insured patients not provide a to that In changes to and transplant should not to status quo quo in Scopus Google Scholar If the not in reducing disparities, transplant should consider eliminating the allocation of deceased donor kidneys to predialysis patients. for preemptively listed patients who start dialysis, their waiting list priority time should be to the date start dialysis so that their priority is to patients waitlisted after starting dialysis. 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