Meeting News

Speaker: ‘Flawed metrics create flawed allocation models’ in kidney transplantation

Jayme Locke

PHOENIX — The metric currently used to evaluate the impact of kidney allocation policies needs to be addressed to ensure a more equitable distribution of organs, according to a speaker at Cutting Edge of Transplantation: Transplant Summit.

“I think we can all agree that we have a major issue between the demand for organs and supply,” Jayme Locke, MD, MPH, FACS, FAST, of the University of Alabama at Birmingham, said. “The challenge becomes: How do we ensure equity in the context of a limited supply? In many ways, as we are debating the concept of equity. We’re kind of re-arranging the deckchairs on the Titanic.”

While Locke acknowledged the new kidney allocation system has increased transplant rates among certain vulnerable populations, including African American patients, she argued the metric currently used to define and quantify disparities is inherently flawed. By using the Organ Procurement and Transplantation Network’s definition of the transplant rate (“number of transplants performed in a time period divided by the waiting list),” the critical (and “flawed”) assumption, she said, is that the waitlist size accurately reflects the end-stage disease burden. The question, Locke proposed, is “Do all of our ESRD patients actually have the opportunity to make it to the waitlist?”

Locke stressed that the metric used to assess transplantation access must reflect disease burden for ESRD, rather than just considering center-specific practices. For instance, she cited a study that found the prevalence of ESRD was positively correlated with a history of stroke. In “the stroke belt,” there is overlapping disease prevalence that “underscores the need to consider disease burden in both organ supply and allocation,” as disease burden impacts organ supply, she said. While ESRD burden is the highest in the Southeastern United States, more patients are not on the waiting lists and higher transplant rates are not occurring. Furthermore, 90,000 to 100,000 U.S. patients are on the waitlist at any given time, though more than 200,000 are “in theory” eligible for transplantation. “Why is that?” Locke asked the audience. “What are we doing to address that? Is it possible that some of these patients are so socially vulnerable that they don’t have the resources to make it to a transplant center?”

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The metric currently used to evaluate the impact of kidney allocation policies needs to be addressed.
Source: Adobe Stock

She added there are no standards by which transplant centers wait-list patients, an area she said also needs investigation.

Locke suggested modifying the metric to incorporate disease burden will help identify the areas of greatest need and uncover the organ procurement organizations with poor performance.

She said, “It will allow for us to hold centers accountable for serving their population and it allows allocation algorithms to exist that ensure available organs are supplied to areas with the greatest needs, which is what our patients are asking for.” – by Melissa J. Webb

Reference:

Locke J. Defining equity — How have allocation policies addressed disparities in transplantation and where do opportunities still lie? Presented at Cutting Edge of Transplantation: Transplant Summit. March 5-7, 2020; Phoenix.

Disclosure: Locke reports consulting for Sanofi.

 

Jayme Locke

PHOENIX — The metric currently used to evaluate the impact of kidney allocation policies needs to be addressed to ensure a more equitable distribution of organs, according to a speaker at Cutting Edge of Transplantation: Transplant Summit.

“I think we can all agree that we have a major issue between the demand for organs and supply,” Jayme Locke, MD, MPH, FACS, FAST, of the University of Alabama at Birmingham, said. “The challenge becomes: How do we ensure equity in the context of a limited supply? In many ways, as we are debating the concept of equity. We’re kind of re-arranging the deckchairs on the Titanic.”

While Locke acknowledged the new kidney allocation system has increased transplant rates among certain vulnerable populations, including African American patients, she argued the metric currently used to define and quantify disparities is inherently flawed. By using the Organ Procurement and Transplantation Network’s definition of the transplant rate (“number of transplants performed in a time period divided by the waiting list),” the critical (and “flawed”) assumption, she said, is that the waitlist size accurately reflects the end-stage disease burden. The question, Locke proposed, is “Do all of our ESRD patients actually have the opportunity to make it to the waitlist?”

Locke stressed that the metric used to assess transplantation access must reflect disease burden for ESRD, rather than just considering center-specific practices. For instance, she cited a study that found the prevalence of ESRD was positively correlated with a history of stroke. In “the stroke belt,” there is overlapping disease prevalence that “underscores the need to consider disease burden in both organ supply and allocation,” as disease burden impacts organ supply, she said. While ESRD burden is the highest in the Southeastern United States, more patients are not on the waiting lists and higher transplant rates are not occurring. Furthermore, 90,000 to 100,000 U.S. patients are on the waitlist at any given time, though more than 200,000 are “in theory” eligible for transplantation. “Why is that?” Locke asked the audience. “What are we doing to address that? Is it possible that some of these patients are so socially vulnerable that they don’t have the resources to make it to a transplant center?”

#
The metric currently used to evaluate the impact of kidney allocation policies needs to be addressed.
Source: Adobe Stock

She added there are no standards by which transplant centers wait-list patients, an area she said also needs investigation.

Locke suggested modifying the metric to incorporate disease burden will help identify the areas of greatest need and uncover the organ procurement organizations with poor performance.

She said, “It will allow for us to hold centers accountable for serving their population and it allows allocation algorithms to exist that ensure available organs are supplied to areas with the greatest needs, which is what our patients are asking for.” – by Melissa J. Webb

Reference:

Locke J. Defining equity — How have allocation policies addressed disparities in transplantation and where do opportunities still lie? Presented at Cutting Edge of Transplantation: Transplant Summit. March 5-7, 2020; Phoenix.

Disclosure: Locke reports consulting for Sanofi.

 

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