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Is Exclusion of Coronary Artery Disease in the Kidney Allocation System Preventing Optimal Longevity Matching?
1Department of Transplant Nephrology, John C. McDonald Regional Transplant Center, Willis-Knighton Medical Center, Shreveport, LA.
Insights
Coronary artery disease (CAD) in kidney transplant candidates increases mortality and graft loss. Excluding CAD history from kidney allocation hinders matching donor kidneys for long-term survival.
Area of Science:
- Nephrology
- Cardiology
- Transplant Surgery
Background:
- Coronary artery disease (CAD) is a significant predictor of mortality in kidney transplant candidates.
- The impact of excluding CAD from kidney allocation on longevity matching is unknown.
Purpose of the Study:
- To evaluate the effect of coronary artery disease (CAD) on kidney transplant outcomes.
- To assess whether the exclusion of CAD in kidney allocation impacts longevity matching.
Main Methods:
- Observational study of adult deceased donor kidney transplant recipients (2014-2018) with Medicare FFS insurance.
- Patients categorized by Kidney Donor Profile Index (KDPI), Estimated Posttransplant Survival (EPTS), and CAD status.
- Outcomes included mortality, graft loss, and death-censored graft loss.
Main Results:
- Patients with CAD had significantly higher risks of mortality, death with functioning graft, overall graft loss, and death-censored graft loss (P < 0.05).
- Higher mortality in the CAD group was observed across KDPI categories and for EPTS 0-20% receiving KDPI <20% kidneys (P < 0.001).
- Preexisting CAD, CAD with stents, or bypass surgery increased mortality and graft loss risks (HRs 1.38-2.76). Posttransplant CAD events were higher in patients with preexisting CAD (P < 0.001).
Conclusions:
- Excluding candidates' history of CAD from kidney allocation adversely affects the goal of optimal longevity matching.
- Current kidney allocation systems may not adequately account for CAD, potentially impacting long-term transplant success.
Background:
Coronary artery disease (CAD) in a kidney transplant candidate is an important predictor of posttransplant mortality. It is not known how the exclusion of CAD in the kidney allocation system has impacted its goal of longevity matching.
Methods:
This is an observational study on adult deceased donor kidney transplant alone recipients between December 4, 2014, and December 31, 2018, with Medicare fee for service (FFS) insurance. Patients were categorized on the basis of Kidney Donor Profile Index (KDPI), Estimated Posttransplant Survival (EPTS), and CAD. Outcomes studied were mortality, death with a functioning graft, overall graft loss, and death-censored graft loss.
Results:
Among 21 151 patients with Medicare FFS coverage for >1 y before transplant, there were 2869 and 18 282 patients with and without CAD, respectively. On Kaplan-Meier analysis, there was higher risk of mortality, death with a functioning graft, overall graft loss, and death-censored graft loss with CAD ( P < 0.05 for all). Mortality was higher for CAD group within each category of KDPI and among patients with Estimated Posttransplant Survival 0% to 20% receiving kidneys with KDPI <20% ( P < 0.001 for all). On Cox multivariate analysis, the hazard ratios (HRs) of mortality and graft loss were higher with CAD diagnosis without intervention (HR 1.38 [1.25-1.52] and 1.29 [1.18-1.4]), CAD with stents (HR 2.76 [1.68-4.53] and 2.36 [1.46-3.81]), and CAD with bypass surgery (HR 1.56 [1.29-1.89] and 1.39 [1.17-1.65]). Posttransplant CAD events were higher in patients with preexisting CAD ( P < 0.001).
Conclusions:
The exclusion of a candidate's history of CAD in the kidney allocation system adversely impacts its goal of optimal longevity matching.
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