Expanding the access to kidney transplantation: Strategies for kidney transplant programs.

Kidney transplantation is the most successful kidney replacement therapy available, resulting in improved recipient survival and societal cost savings. Yet, nearly 70 years after the first successful kidney transplant, there are still numerous barriers and untapped opportunities that constrain the access to transplant. The literature describing these barriers is extensive, but the practices and processes to solve them are less clear. Solutions must be multidisciplinary and be the product of strong partnerships among patients, their networks, health care providers, and transplant programs. Transparency in the referral, evaluation, and listing process as well as organ selection are paramount to build such partnerships. Providing early culturally congruent and patient-centered education as well as maximizing the use of local resources to facilitate the transplant work up should be prioritized. Every opportunity to facilitate pre-emptive kidney transplantation and living donation must be taken. Promoting the use of telemedicine and kidney paired donation as standards of care can positively impact the work up completion and maximize the chances of a living donor kidney transplant.

Disparities in telemedicine utilization among kidney transplant patients during the COVID-19 pandemic: Barriers and opportunities.

INTRODUCTION: The COVID-19 pandemic allowed for the rapid implementation of telemedicine for kidney transplant patients; however, widespread adoption may worsen existing health care inequities among vulnerable populations. This study aimed to characterize telemedicine utilization by kidney transplant patients during the early pandemic with particular attention to healthcare equity. METHODS: A retrospective analysis of kidney transplant patients interacting with telemedicine was performed. Patient demographic data and distance to the transplant center were obtained. The National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme for Counties and Brokamp Neighborhood Deprivation Index (NDI) score were used to characterize patients' counties of residence. Multivariable logistic regression evaluated associations between patient and community characteristics and the likelihood of an encounter being telemedicine. RESULTS: This study included 1033 patients who participated in 3727 encounters from March 11 through October 2020. Characteristics associated with decreased likelihood of telemedicine use were increased age (OR = .993; 95% CI = .986-.999, P = .022), non-White vs. White race (OR = .826, 95% CI = .697-.979; P = .028), male vs. female sex (OR = .746, 95% CI = .632-.880; P < .001), and a higher Brokamp Neighborhood Deprivation Index score (OR = .159; 95% CI = .029-.873; P = .034). The effect of distance to the transplant center on the likelihood of a telemedicine encounter differed by NCHS Urban-Rural designation (interaction P = .018), with its likelihood increasing by 2%-3% with each 10-mile increment among persons residing in medium-, small-, and non-metropolitan counties compared to those residing in the most rural counties. CONCLUSIONS: Telemedicine visits were less often completed by patients of older age, non-white race, male sex, and those residing in counties having higher NDI scores. While telemedicine has the potential to improve healthcare access and decrease costs, proactive efforts need to be taken to mitigate disparities in vulnerable populations.

Center-level Variation in HLA-incompatible Living Donor Kidney Transplantation Outcomes.

BACKGROUND: Desensitization protocols for HLA-incompatible living donor kidney transplantation (ILDKT) vary across centers. The impact of these, as well as other practice variations, on ILDKT outcomes remains unknown. METHODS: We sought to quantify center-level variation in mortality and graft loss following ILDKT using a 25-center cohort of 1358 ILDKT recipients with linkage to Scientific Registry of Transplant Recipients for accurate outcome ascertainment. We used multilevel Cox regression with shared frailty to determine the variation in post-ILDKT outcomes attributable to between-center differences and to identify any center-level characteristics associated with improved post-ILDKT outcomes. RESULTS: After adjusting for patient-level characteristics, only 6 centers (24%) had lower mortality and 1 (4%) had higher mortality than average. Similarly, only 5 centers (20%) had higher graft loss and 2 had lower graft loss than average. Only 4.7% of the differences in mortality (P < 0.01) and 4.4% of the differences in graft loss (P < 0.01) were attributable to between-center variation. These translated to a median hazard ratio of 1.36 for mortality and 1.34 of graft loss for similar candidates at different centers. Post-ILDKT outcomes were not associated with the following center-level characteristics: ILDKT volume and transplanting a higher proportion of highly sensitized, prior transplant, preemptive, or minority candidates. CONCLUSIONS: Unlike most aspects of transplantation in which center-level variation and volume impact outcomes, we did not find substantial evidence for this in ILDKT. Our findings support the continued practice of ILDKT across these diverse centers.

The Transplant Nephrology Workforce in the United States: Current State and Future Directions.

The population of patients with kidney transplants in the United States is growing. The delivery of transplant care is complex, involves a multidisciplinary transplant team, and care coordination between transplant and community providers. The transplant nephrologist is central to the delivery of this care and assumes a multitude of clinical and nonclinical roles and responsibilities. With a growing population of patients requiring transplant care that spans a continuum from pretransplant referral to long-term posttransplant management, an understanding of the current state of the transplant nephrology workforce in the United States and the future that it faces is important in ensuring that current and future needs of both patients and physicians are met. In this article, we (1) review the scope of practice of the transplant nephrologist, (2) discuss the state of training in the field of transplant nephrology, (3) review the role of the referring primary nephrologist in the care of patients undergoing kidney transplant, and (4) discuss challenges and opportunities facing the transplant nephrology workforce.

Geographic Disparities in Access to Simultaneous Pancreas and Kidney Transplant in the Pre- and Post-Pancreas Allocation System Eras.

BACKGROUND: The 2014 pancreas allocation system (PAS) intended to decrease geographic variability in listing practices for simultaneous pancreas and kidney (SPK) transplant and define eligibility criteria for those with type 2 diabetes mellitus (T2DM). Our primary aims were to evaluate geographic disparities in access to SPK and assess T2DM SPK listings in the pre- and post-PAS eras. METHODS: Adult listings for SPK and kidney transplant (pre-PAS, January 2010 to October 29, 2014; post-PAS, October 30, 2014, to June 2, 2017) were identified in the Scientific Registry of Transplant Recipients. Multivariable logistic regression models tested associations of geography and/or diabetes mellitus type on the likelihood of SPK versus kidney transplant listing pre- and post-PAS. Competing risk models tested the likelihood of SPK transplantation within 2 years of listing for SPK. RESULTS: Among 41 205 listings (27 393 pre-PAS; 24 439 T2DM), univariate analysis showed reduced percentages for SPK post-PAS (22.1%-20.8%; P = 0.003). After adjusting for patient and center characteristics, geographic disparities declined slightly but persisted post-PAS (era by region interaction P < 0.001). The era by type of diabetes mellitus interaction effect was statistically significant (P = 0.039), reflecting that the proportions of SPK listings for T2DM increased in the post-PAS era (3.4%-3.9%; univariate P = 0.038), while those for type 1 diabetes mellitus remained statistically stable (47.9%-48.4%; univariate P = 0.571). Among people listed for SPK, geographic disparities in the cumulative incidence of transplantation within 2 years declined and the overall likelihood of transplantation increased in the post-PAS era (both P < 0.001). CONCLUSIONS: Geographic disparities in access to SPK declined slightly but persisted post-PAS. With new allocation change proposals and elimination of listing criteria for T2DM, further monitoring is warranted.

The Kidney Transplant Evaluation Process in the Elderly: Reasons for Being Turned down and Opportunities to Improve Cost-Effectiveness in a Single Center.

Background. The kidney transplant evaluation process for older candidates is complex due to the presence of multiple comorbid conditions. Methods. We retrospectively reviewed patients ≥60 years referred to our center for kidney transplantation over a 3-year period. Variables were collected to identify reasons for patients being turned down and to determine the number of unnecessary tests performed. Statistical analysis was performed to estimate the association between clinical predictors and listing status. Results. 345 patients were included in the statistical analysis. 31.6% of patients were turned down: 44% due to coronary artery disease (CAD), peripheral vascular disease (PVD), or both. After adjustment for patient demographics and comorbid conditions, history of CAD, PVD, or both (OR = 1.75, 95% CI (1.20, 2.56), p = 0.004), chronic obstructive pulmonary disease (OR = 8.75, 95% CI (2.81, 27.20), p = 0.0002), and cancer (OR 2.59, 95% CI (1.18, 5.67), p = 0.02) were associated with a higher risk of being turned down. 14.8% of patients underwent unnecessary basic testing and 9.6% underwent unnecessary supplementary testing with the charges over a 3-year period estimated at $304,337. Conclusion. A significant number of older candidates are deemed unacceptable for kidney transplantation with primary reasons cited as CAD and PVD. The overall burden of unnecessary testing is substantial and potentially avoidable.