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Published on: April 12, 2021
Disparities in Access to Timely Waitlisting Among Pediatric Kidney Transplant Candidates
Lindsey M Maclay1,2, Miko Yu1,2, Sandra Amaral3,4
1Departments of Medicine, Division of Nephrology.
Insights
Disparities exist in timely kidney transplant waitlisting for children with end-stage kidney disease. Delays in waitlisting, particularly for young adults, can lead to increased dialysis exposure and missed pediatric prioritization.
Area of Science:
- Pediatric Nephrology
- Transplant Surgery
- Health Services Research
Background:
- Optimal outcomes for pediatric end-stage kidney disease (ESKD) patients are achieved with kidney transplantation and minimal dialysis exposure.
- Timely access to the kidney transplant waitlist is crucial for pediatric ESKD patients.
Purpose of the Study:
- To investigate disparities in timely access to kidney transplant waitlisting among pediatric candidates.
- To examine the association between preemptive waitlisting and transplantation outcomes.
- To identify challenges faced by young adults who miss pediatric prioritization.
Main Methods:
- Retrospective, registry-based cohort study of US pediatric kidney transplant candidates (ages 3-17) from 2015-2019.
- Defined "preemptive waitlisting" as waitlist addition before dialysis initiation.
- Used competing risk regression to analyze associations between waitlisting status, dialysis exposure, and transplantation.
Main Results:
- 48% of 4506 pediatric candidates were waitlisted preemptively.
- Female sex, Hispanic ethnicity, Black race, and public insurance were linked to lower preemptive waitlisting rates.
- Preemptive waitlisting did not significantly affect time to transplantation post-activation, but reduced pretransplant dialysis duration.
- Young adults waitlisted after initiating dialysis as children had significantly lower transplant rates.
Conclusions:
- Disparities in waitlisting timing correlate with differences in pretransplant dialysis exposure.
- Young adults experiencing waitlist delays may miss critical pediatric allocation benefits.
- Policy interventions are needed to address these access disparities and ensure equitable transplantation for pediatric ESKD patients.
Background And Objectives:
Kidney transplantation with minimal or no dialysis exposure provides optimal outcomes for children with end-stage kidney disease. We sought to understand disparities in timely access to transplant waitlisting.
Methods:
We conducted a retrospective, registry-based cohort study of candidates ages 3 to 17 added to the US kidney transplant waitlist 2015 to 2019. We defined "preemptive waitlisting" as waitlist addition before receiving dialysis and compared demographics of candidates based on preemptive status. We used competing risk regression to determine the association between preemptive waitlisting and transplantation. We then identified waitlist additions age >18 who initiated dialysis as children, thereby missing pediatric allocation prioritization, and evaluated the association between waitlisting with pediatric prioritization and transplantation.
Results:
Among 4506 pediatric candidates, 48% were waitlisted preemptively. Female sex, Hispanic ethnicity, Black race, and public insurance were associated with lower adjusted relative risk of preemptive waitlisting. Preemptive listing was not associated with time from waitlist activation to transplantation (adjusted hazard ratio 0.94, 95% confidence interval 0.87-1.02). Among transplant recipients waitlisted preemptively, 68% had no pretransplant dialysis, whereas recipients listed nonpreemptively had median 1.6 years of dialysis at transplant. Among 415 candidates initiating dialysis as children but waitlisted as adults, transplant rate was lower versus nonpreemptive pediatric candidates after waitlist activation (adjusted hazard ratio 0.54, 95% confidence interval 0.44-0.66).
Conclusions:
Disparities in timely waitlisting are associated with differences in pretransplant dialysis exposure despite no difference in time to transplant after waitlist activation. Young adults who experience delays may miss pediatric prioritization, highlighting an area for policy intervention.
