Patients with greatest potential survival benefit of transplant commonly not wait-listed
Research from the Cleveland Clinic showed less than half of patients who might reap the most benefits from kidney transplantation, deemed high priority based on estimated post-transplant survival score, were placed on the waitlist.
Significant disparities were also identified here, with patients who were Black, had lower incomes or who lacked commercial insurance being less likely to be wait-listed.
Estimated post-transplant survival score
“One of the key changes with the deceased donor Kidney Allocation System (KAS) in 2014 was the introduction of the estimated post-transplant survival (EPTS) score, designed to identify candidates with the longest expected post-transplant survival, and preferentially allocate the highest-quality kidneys to these patients,” Jesse D. Schold, PhD, and colleagues wrote. “The EPTS score creates an index estimating patient survival after kidney transplantation on a 0%-100% scale compared with all other candidates on the waiting list on the basis of age, diabetes status, history of prior organ transplants and time on dialysis. As a result, younger candidates without diabetes who have not had a prior transplant and with little or no time on maintenance dialysis have lower EPTS scores. Candidates with EPTS score [of at least] 20% (“top 20%” EPTS status) have preferential access to deceased donor kidney offers with the lowest cumulative risk factors (top 20% kidney donor profile index offers) before other candidates at the local, regional, and national level.
Importantly, EPTS is a dynamic score such that a given patient’s score changes continuously on the basis of age, time on dialysis (if applicable), or any reported changes in diabetic or transplant status, and patients will eventually lose top 20% status over time.”
The purpose of this study, according to Schold and colleagues, was to assess how frequently patients with “top 20% EPTS status” are placed on the waitlist and to examine factors associated with placement.
“These results may help identify patients with greatest benefit from rapid waitlist placement and transplantation, and consider targeted interventions and policies to optimize care for this population,” the researchers wrote.
To this end, Schold and colleagues analyzed data from the United States Renal Data System, including 42,445 patients with top 20% EPTS scores who had been preemptively wait-listed (n = 7,922) or who initiated dialysis between 2015 and 2017 (n = 34,523; 3-year cumulative incidence of waitlist placement was 37%).
Disparities within waitlist placement, access to transplantation
Dialysis initiation was associated with lower access to transplant, with 61% of these patients losing their top 20% EPTS status within 30 months compared with 18% who were preemptively wait-listed. Further, the 3-year incidence of deceased and living donor transplantation was 5% and 6%, respectively, for patients who initiated dialysis compared with 26% and 44% for those who were preemptively listed.
Schold and colleagues also identified various factors that were independently associated with placement on a waitlist. In addition to race, income and insurance status, a decreased likelihood of waitlisting was observed for unemployed or retired patients, as well as patients with morbid obesity. A primary diagnosis of diabetes and hypertension also appeared to lower the likelihood of waitlisting compared with a primary diagnosis of glomerulonephritis.
“There were many individual patient factors associated with incidence of waitlist placement including demographic characteristics, comorbid conditions, and factors reflecting the patient’s socioeconomic and social environment (ie, employment, residential area income, insurance). These results highlight that even among relatively young and healthy patients, barriers to care exist, including by race and socioeconomic status,” the researchers wrote. “ ... The results must also be placed in the context that, despite our understanding of the need to improve access to transplants and remove existing barriers to transplants, there have been no measurable improvements in more than  decades. As such, there is a need for more comprehensive and impactful policy reforms and interventions to improve access to care.”
Schold provided further insight in a related press release, noting there are many patients with kidney failure who qualify for top 20% EPTS status but who do not receive placement on the waitlist.
“This is important given the high likelihood that these patients would benefit from transplantation and that they will lose top 20% status in the future,” Schold said. “As such, expedited placement on the waiting list for these patients is critically important.”