Background: The UNOS kidney allocation policy has evolved since first introduced in the 1980s. In 2002 there was a reduction in the number of points given for HLA-matching because it significantly disadvantaged minorities, despite the better 1- and 5-year survival for HLA-matched kidneys.[1] The 2012 Kidney Committee proposal changes accrual of points from listing to initiation of dialysis. Both the current and new proposals also allow for accrual of waitlist points if estimated GFR <20ml/min/1.73m² which allows some candidates to receive a deceased donor kidney transplant (DDKT) preemptively (i.e., prior to starting dialysis). Purpose: Given the various socioeconomic barriers that hinder waitlist access, we explored 1) equity issues in preemptive DDKT; and 2) graft survival advantage from preemptive DDKT. Methods: We analyzed kidney waitlist data from the UNOS Standard of Transplant Analysis and Research dataset using SPSS 20. We determined demographics of adults (> 18 years) who received a preemptive DDKT and performed Kaplan-Meier actuarial graft survival analyses to assess benefit. Binary logistic regressions evaluated demographics associated with preemptive DDKT. Results: Of the 89,075 DDKT performed between 9/30/00-10/1/10, 16,801 (19%) were preemptive. When compared to White recipients, Blacks (OR: .44[.42-.46]) and Hispanics (OR: .37 [.35-.40]) were less likely to receive preemptive DDKT. Whites accounted for 38.8% of individuals on the waitlist, 47.8% of all DDKT, and 64.1% of preemptive DDKT. Comparable values were 34.5%, 31.2%, and 21.3% for Blacks and 17.7%, 13.4%, and 7.8% for Hispanics. The benefit of preemptive DDKT becomes more significant over time. Overall, 1- and 5-year graft survival of preemptive transplant recipients was 92.9% and 82.3 % compared to 90.4% and 74.9% for transplant recipients on dialysis. Benefit from preemptive transplant was greatest for Whites (83.6 vs 74.4%) > Blacks (76.5 vs 71.5 %) > Hispanics (83.7 vs 80.7%). Smaller but significant bias based on age and gender was also seen in terms of who received preemptive transplants. Conclusion: The current UNOS policy allows preemptive DDKT even though preemptive DDKT exacerbate racial/ethnic disparities. While preemptive DDKT have better long-term outcomes, this must be balanced against the inequities created. Eliminating preemptive point accrual and initiating point accrual at start of dialysis for all candidates will sacrifice some efficiency for equity, for which there is precedence.[1] Reference: 1) Ting A, Edwards LB. Transplant. 2004;77: 610-33.

« Back to 2013 American Transplant Congress