Effect of age and care organization on sources of variation in kidney transplant waiting list registration

Despite national guidelines, medical practices and kidney transplant waiting list registration policies may differ from one dialysis/transplant unit to another. Benefit risk assessment variations, especially for elderly patients, have also been described. The aim of this study was to identify sources of variation in early kidney transplant waiting list registration in France. Among 16 842 incident patients during the period 2016–2017, 4386 were registered on the kidney transplant waiting list at the start of, or during the first year after starting, dialysis (26%). We developed various log-linear mixed effect regression models on three levels: patients, dialysis networks, and transplant centers. Variability was expressed as variance from the random intercepts (± standard error). Although patient characteristics have an important impact on the likelihood of registration, the overall magnitude of variability in registration was low and shared by dialysis networks and transplant centers. Between-transplant center variability (0.23 ± 0.08) was 1.8 higher than between-dialysis network variability (0.13 ± 0.004). Older age was associated with a lower probability of registration and greater variability between networks (0.04, 0.20, & 0.93 in the 18–64, 65–74, and 75–84 age groups). Targeted interventions should focus on elderly patients and/or certain regions with greater variability in waiting list access.     

Access to preemptive registration on the waiting list for renal transplantation: a hierarchical modeling approach

Preemptive kidney transplantation is associated with both longer patient and graft survival. This study was carried out to estimate the association between the renal units and preemptive registration on the waiting list for first deceased donor renal transplantation in a French network of care. From 2008 to 2012, 1529 adult patients followed in 48 units of the French North‐West network and registered on the waiting list for a first deceased donor renal allograft were included. We used a mixed logistic regression with renal units as random‐effects term for statistical analysis. Of the 1529 patients included, 407 were placed on the waiting list preemptively. There was a significant variability across renal units (variance 0.452). In multivariate analysis, factors independently associated with preemptive registration were cardiovascular disease (odds ratio (OR) 0.57, [95% CI: 0.42–0.79]), social deprivation (OR 0.73, [95% CI 0.57–0.94]), and renal units' characteristics (ownership of the facility: academic hospital, reference—community hospital, OR 0.44, [95% CI 0.24–0.80]—private hospital, OR 0.35, [95% CI 0.18–0.69] and transplant center; P < 0.10]. Variability between renal units was reduced after taking into account their characteristics but was not influenced by patient characteristics. Preemptive registration is associated with renal units, transplant centers, and social deprivation and can be partly explained by disparities in practices.     

A New Approach for Measuring Gender Disparity in Access to Renal Transplantation Waiting Lists

BACKGROUND: Gender inequity in access to renal transplantation waiting lists, in favor of men, has long since been demonstrated in a number of studies. Discrepancies between the results of the available studies might be explained by different analytical approaches or different national contexts. In this study we analyzed French end-stage renal disease registry data using a novel model to determine whether the female gender is associated with a lower probability of being listed on the transplant waiting list or with a longer time from dialysis start until registration, or both. METHODS: The effect of gender on access to the national renal transplantation waiting list was assessed in 9497 men and 5386 women aged 18 to 74 years who started dialysis between 2002 and 2009. We used a semiparametric regression cure model adjusted for age, work status, and 11 comorbidities or disabilities. RESULTS: Women were younger and less likely to work or have associated comorbidities. At the study endpoint, 33.8% of the men and 34.1% of the women were placed on the renal transplantation waiting list. After taking potential confounders into account, our model shows that women demonstrated a lower probability of being registered on the national transplant waiting list (odds ratio=0.69; 95% confidence interval, 0.62-0.78) and a longer time from dialysis start to registration (hazard ratio=0.89; 95% confidence interval, 0.84-0.95) than men. This disparity affects predominantly older women who do not work or have diabetes and is more pronounced in some geographic areas. CONCLUSIONS: These poorly understood gender-based inequities require further consideration.     

Outcome‐dependent geographic and individual variations in the access to renal transplantation in incident dialysed patients: a French nationwide cohort study

This study investigated geographical variations of access to renal transplantation using three outcomes (access to the transplant waiting list, access to renal transplantation after waitlisting and access to renal transplantation after dialysis start). Associations of patient‐related and regional variables with the studied outcomes were assessed using a Cox shared frailty model and a Fine and Gray model. At the study endpoint (December 31, 2015), 26.3% of all 18–90‐year‐old patients who started dialysis in the 22 mainland and four overseas French regions in 2012 (n = 9312) were waitlisted and 15.1% received a kidney transplant. The geographical disparities of access to renal transplantation varied according to the studied outcome. Patients from the Ile‐de‐France region had the highest probability of being waitlisted, but were less likely to receive a kidney transplant. Two regional factors were associated with the access to the waiting list and to renal transplantation from dialysis start: the incidence of preemptive kidney transplantation and of ESRD. The use of different outcomes to evaluate access to kidney transplantation could help healthcare policy‐makers to select the most appropriate interventions for each region in order to reduce treatment disparities.     

Access to, and outcome of, renal transplantation according to treatment modality of end-stage renal disease in France

BACKGROUND: Although peritoneal dialysis (PD) is recognized as one of the methods of treatment of end-stage renal disease (ESRD), there have been recurrent concerns about the access of patients treated by this modality to kidney transplantation (KTx), as well as reports showing increased complications of KTx in such patients, such as graft thrombosis and infections. METHODS: The aim of this study was to provide a comprehensive view of the impact on transplantation of pretransplant modality of treatment of ESRD using a multivariate analysis of the French database. From 1997 to 2000, after exclusion of pediatric patients, multiple transplantations, and living donors, 6420 were patients registered on the waiting list, and 3464 were transplanted. RESULTS: Using a Cox proportional hazard analysis, we found a shorter waiting time for PD patients (RR 0.71, P < 0.0001), which became equivalent to hemodialysis (HD) patients when taking into account the transplant center as a variable (RR 1.0, P= 0.95). Concerning graft survival, only preemptive transplantation had a significant impact, being associated to a decreased risk of graft failure (RR 0.46, P= 0.005). Conclusion. Our study supports the concept that the choice of any pretransplant dialysis modality does not influence waiting time for transplant or the results of transplantation.     

Access to kidney transplantation in France of non-French patients and French patients living in overseas territories

BACKGROUND: In France, foreign patients, whether resident or not in France, can register on the national waiting list under certain conditions. We compared waiting time to kidney transplantation, the level of HLA matching and graft cold ischemia time between foreign patients and French patients living in mainland France or in French overseas territories (FOT). METHODS: We performed a retrospective cohort survey using the nationwide registry. Between 1996 and 2003, 18,595 patients were registered on the French waiting list. Of these, 9.9% were of non-French nationality (0.7% Greek, 1.4% Italian, 1.5% other European, 3.7% North African, 1.8% sub-Saharan African and 0.9% other), and 3.8% were French nationals living in FOT. RESULTS: Median waiting time differed significantly between groups, from 13.8 months for mainland French patients to 39.5 months for sub-Saharan African patients. After adjustment for other factors significantly linked to waiting time, French residents of FOT (RR=0.83; P<0.001) and patients from sub-Saharan Africa (RR=0.75; P<0.0001) were found to wait significantly longer than other patients. HLA matching level, particularly HLA-A and HLA-B, was worse for African patients. After adjustment for the transplant team, cold ischemia time was found to be longer for Greeks (30.4 hr, P<0.0001) and French patients living in FOT (33.3 hr, P<0.0001) than for mainland French patients (21.2 hr). CONCLUSIONS.: Programs promoting organ donation aimed at minorities of African origin should improve their access to transplantation in France. We also need to strengthen international cooperation programs in certain countries to assist access to transplantation and to increase graft quality.     

Geographic variance in access to renal transplantation in Australia

BACKGROUND: Geographic disparities in access to transplantation in Australia during the past 15 years have been accentuated by the increasing size of the transplant waiting lists in each state and by low cadaveric donation rates. Access to dialysis treatment is similar in all states of Australia, although there are fewer elderly dialysis patients in South Australia. RESULTS: Access to the transplant waiting list varies significantly between the states, with one state having 39 per million population (pmp) on their list compared with the two most populous states at 113 pmp and 101 pmp. Patients between the ages of 25 and 54 years in one state had twice the chance of being on the waiting list compared with another.Transplantation rates reflect both the cadaveric donor rate (16.9 transplants pmp) and the large contribution from living donors (39% of all transplants in 2001). Transplantation with a kidney in Australia is dependent both upon age and the state of residence, with one state performing transplantations with 15% of their dialysis population each year but all other states achieving less than 10%, with an average of 8% for the country as a whole. CONCLUSIONS: Criteria for access to the transplantation waiting list in each state vary, depending perhaps upon whether a general community or individual patient perspective is the dominant policy. Access to transplantation on the other hand is reflective of each states' cadaveric donation rate modified by increasing use of living donors, especially in younger patients.     

2017 Annual Report Digest of the Renal Epidemiology Information Network (REIN) registry

The French Renal Epidemiology and Information Network (REIN) registry started in 2002 with the goal to provide a tool to evaluate renal replacement therapy (RRT) practices and outcomes, to provide data for research and to support public health decisions related to end‐stage renal disease ESRD. This summary presents the incidence and prevalence of RRT including kidney transplantation and wait‐listing activity in 2017, and patients’ survival and trends over 5 years. In 2017, 11 543 patients started RRT for ESRD, that is, incidence of 172 pmp. Between 2012 and 2017, the incidence of RRT increased by 1% per year [CI 95% (0.0; +2.0)]. On 31 December 2017, 87 275 patients were receiving RRT, that is, prevalence of 1294 pmp, 55% on dialysis, 45% with a functioning transplant. In 2017, 3782 kidney transplantations have been performed including 16% from a living donor, 13% being retransplantations and 15% pre‐emptive transplantations. The median time on the waiting list was 19.7 months when only taking into account active waiting periods on the list. In 2017, 5280 new patients were registered on the renal transplant waiting list (i.e. 78.7 pmp). The number of patients considered as ‘inactive’ represented 45% of the patients on the list.     

Estimation des besoins en greffe rénale au Maroc

Kidney transplantation is still underdeveloped in Morocco. In order to anticipate needs and discuss a possible reorganization of the provision of care, an estimate of the number of patients who would benefit from kidney transplant was conducted. This study was done in two steps. During the first step, based on the French renal replacement therapy registry (Rein), we develop a prediction score based on the likelihood of being treated by an autonomous dialysis (hemodialysis in self-care unit or peritoneal dialysis non-assisted by a nurse) and be registered on the national kidney transplant waiting list. During the second step, we apply this score to the data of the registry Magredial (Moroccan registry of renal replacement therapy, deployed in seven regions). Twelve parameters were related to autonomy and registration on the waiting list. Each of these parameters has been assigned a weight. Each patient was assigned a number of points, sum of different weights. By retaining a threshold of 21 points (80% specificity), 2260 subjects (57%) had a score less than or equal to this threshold in Magredial. With a number of patients on dialysis in Morocco estimated to 13,000 in late 2013, the estimated need for kidney transplant will be of 7410. This estimate should encourage professionals and health authorities of Morocco to engage more effort in the implementation of actions related to the transplant program.     

Renal Transplantation in the Roma Ethnicity—Do All Patients Have Equal Chance for Transplantation?

Racial and ethnic disparities exist in access to kidney transplantation worldwide. The Roma people are often socially deprived, uneducated, and unemployed. We investigated all dialysis centers in Croatia to determine number of Roma people on dialysis as well as their access and reasons for eventual failure to enter the waiting list. There are 9463 registered Roma people in Croatia, however, the estimated number reaches 40,000. Twenty-five Roma patients required renal replacement therapy, giving a prevalence of 830 per million people (pmp), compared with 959 pmp among the general population. Average age at the start of dialysis was 29 vs 67 years; waiting time to kidney transplantation was 48.9 vs 53.5 months; mean age at the time of transplantation was 33.18 vs 48.01 years in Roma versus the general population respectively. One patient received a kidney allograft from a living unrelated spousal donor, and all others from deceased individuals. Patients were followed for 51.5 months (range, 6–240).     

Accès à la liste d’attente et à la greffe rénale

This chapter provides a set of indicators related to Renal Transplantation access in France. It describes patient outcomes and reports on cumulative incidence rates of wait-listing and renal transplantation according to main patient of characteristics and regions. The REIN registry integrates kidney transplant and dialysis data. It provides a comprehensive view on waiting list and renal transplantation access to the patients, nephrologists, and national or regional health authorities.Access to the waiting list is evaluated on a cohort of 51,845 new patients who started dialysis between 2002 and 2011 in 25 regions. The probability of first wait-listing was of 3.7% at the start of dialysis (pre-emptive registrations), 15% at 12, 22% at 36 and 24% to 60 months. The probability of being registered was strongly related to age, diabetes and region. Patient older than 60 had a very poor access to the waiting list, whatever their diabetes status was. Probability of first wait-listing was much lower (36.5% at 60 months) in type 2 diabetic-40 to 59 years old patients. Among 13,653 patients less than 60 years old, the probability of being registered was 11% at the start of dialysis, 43% to 12 months, 62% to 36 months and 66% to 60 months (median dialysis duration: 16 months). Seventeen regions with up to 5 years follow-up show an increase of 8 to 15% in pre-emptive registrations between 2007 and 2001, without change at 1 year.Access to kidney transplant is evaluated on a cohort of 53,301 new patients who started a renal replacement therapy (dialysis or pre-emptive renal transplant) between 2002 and 2011 in 25 regions. The probability of first kidney transplant was of 7% at 12, 17% at 36 and 21% at 60 months. 8,633 patients (16,2%) had received a first renal transplant within 14.7 month median time; 1,455 (2.7%) had received a pre-emptive graft [male: 58%, median age: 48.7y]. Among the 14,770 new patients less than 60 years old, the probability of being transplanted was of 21% at 12, 46% at 36 and 58% at 60 months (median dialysis duration: 42 months). When pre-emptive graft were excluded, the probability of being transplanted was of 5% at 12, 15% to 36 and 19% to 60 monthsInsofar as kidney transplant is regarded as the most efficient treatment, access to the waiting list and renal transplant are sensitive issues.     

Individual and Regional Factors of Access to the Renal Transplant Waiting List in France in a Cohort of Dialyzed Patients

Several studies have investigated geographical variations in access to renal transplant waiting lists, but none has assessed the impact on these variations of factors at both the patient and geographic levels. The objective of our study was to identify medical and non‐medical factors at both these levels associated with these geographical variations in waiting‐list placement in France. We included all incident patients aged 18–80 years in 11 French regions who started dialysis between January 1, 2006, and December 31, 2008. Both a multilevel Cox model with shared frailty and a competing risks model were used for the analyses. At the patient level, old age, comorbidities, diabetic nephropathy, non‐autonomous first dialysis, and female gender were the major determinants of a lower probability of being waitlisted. At the regional level, the only factor associated with this probability was an increase in the number of patients on the waiting list from 2005 to 2009. This finding supports a slight but significant impact of a regional organ shortage on waitlisting practices. Our findings demonstrate that patients' age has a major impact on waitlisting practices, even for patients with no comorbidity or disability, whose survival would likely be improved by transplantation compared with dialysis.     

Survival of patients who have been on a waiting list for renal transplantation.

INTRODUCTION: Survival of transplanted patients is generally much better than for those on dialysis. This comparison is, however, incorrect, as in order to be accepted for renal transplantation the patient has to be in a relatively good condition and in addition transplanted patients are usually younger. We compared survival of all renal replacement therapy (RRT) patients who had undergone an identical medical check-up, been accepted, and put on the waiting list for cadaveric-kidney transplantation at Huddinge University hospital. A comparison with patients who were transplanted with a kidney from a living related donor (LD) is also included. METHODS: All patients (n=608) accepted and on the waiting list for renal transplantation between January 1987 and April 1996 formed the basis of the study. Follow-up was terminated on 31 December 1997. Survival was recorded from the date that the patients were accepted and put on the waiting list. As long as the patient was not transplanted and remained on dialysis treatment, survival was considered as 'survival on dialysis', and if transplanted, subsequent survival was defined as 'survival after cadaveric-kidney transplantation'. A patient who had been transplanted remained in that group for the rest of the observation period even if the transplantation had failed and the patient had to go back to dialysis after the surgery. RESULTS: Five-year survival was considerably better after LD-kidney transplantation (94%), than after cadaveric-kidney transplantation (76%) or on chronic dialysis (60%). Cox hazard regression analysis gave an age-adjusted relative risk for death of 0.46 for LD-transplanted and 1.49 for remaining on dialysis compared with cadaveric-transplanted patients. Transplanted patients, however, experienced a higher mortality during the first year after the transplantation than patients still on dialysis. CONCLUSIONS: LD-kidney transplantation is clearly associated with a superior survival. Mortality is relatively high after cadaveric-kidney transplantation, especially during the first months after surgery. Nevertheless, in the long term cadaveric kidney transplanted patients have a better survival than those remaining on dialysis.     

Qui sont ces patients en dialyse non inscrits sur liste d’attente de greffe rénale ?

Access to kidney transplants for patients with end-stage chronic renal disease is a major challenge in France. Registration on the transplant waiting list is a mandatory step to be able to access this technique. The Haute Autorité de santé (HAS) updated, in 2015, the contraindications to access this list. In this context, we wanted to make an inventory of the reasons for non-registration on the renal transplant waiting list in patients on dialysis for at least a year, aged less than 80 years, in France. All patients included in the Epidemiology and Nephrology Information Register (REIN), who were supposed to have their annual monitoring point from August 1 to November 30, 2016 meeting the criteria, were included and a dedicated questionnaire was completed by their dialysis center. Thus, 3172 patients were analyzed: 2302 (73%) had a medical contraindication to transplant, most often (33%) vascular, 458 (14%) refused to be registered, with proportionately more women in this category, and finally in 412 patients (13%), there was no reason given in our questionnaire. However, for 65% of patients in the latter category, an assessment for registration had started. There were therefore, in our cohort, only 144 patients (4.5%) without explanation for the non-registration. This national study is the first to give a view of the reasons for non-registration on the renal transplant list in France. Unsurprisingly, medical contraindication is the primary reason in this population of chronic patients. The high refusal rate should be emphasized and analyzed more precisely, in particular with the patient's point of view. And finally, very few patients have no informed reason or current assessment.     

The influence of socio-demographic factors, treatment perceptions and attitudes to living donation on willingness to consider living kidney donor among kidney transplant candidates.

BACKGROUND: Living donor, compared with cadaveric donor kidney transplantation, is associated with prolonged graft survival and increased life expectancy for patients with end-stage renal disease (ESRD). However, access to living donor transplantation remains variable. Our objective was to further our understanding of the factors associated with the willingness to consider living donor kidney transplant (LDKTx). METHODS: All patients from two tertiary care hospitals being assessed for a LDKTx (n = 81), and a random sample of patients on the waiting list for a cadaveric kidney transplant (CDKTx, n = 133) were invited to participate. A mail survey assessed participants' socio-demographic characteristics, and perceptions of dialysis, CDKTx and LDKTx. Multivariable logistic regression was used to assess the influence of these factors on willingness to consider LDKTx. RESULTS: Adjusting for patient age, employment status and number of close relatives, willingness to consider an LDKTx was independently associated with a lower perceived risk of peri-operative complications to the donor (adjusted OR 3.59, P = 0.02), the perception that the recipient would live longer following living donor transplantation (adjusted OR 4.34, P = 0.003) and greater perceived appropriateness of asking a family member to donate a kidney (adjusted OR 5.06, P = 0.007). CONCLUSION: Among the ESRD patients studied, adjusting for key factors that may be associated with access to LDKTx, perceptions about risks to the donor and benefits to the recipient were independently associated with a willingness to consider LDKTx as a treatment option. Provision of standardized comprehensible information about all treatment options to patients with ESRD may improve acceptance rates for living donor transplantation.     

Organ allocation in pediatric transplantation in France

In France, ministerial decrees in 1995 and 1996 gave children under 16 who are awaiting transplantation national priority for kidneys and livers from donors under 16, and regional priority for kidneys and livers from donors under 30. We analyzed the effects of these changes on waiting time, death on the waiting list, and balance between demand and supply. The percentage of children who received a transplant during the year of registration increased from 40% in 1993 to 67% in 1998 for kidney transplantation, but only from 50% to 67% for liver transplantation. The number of new children registered on the renal transplant waiting list (84 in 1998) and the number transplanted (85 in 1998) are balanced. But, because of the number of children still on the waiting list at the end of each year, there remains an imbalance of about 70 for kidney transplantation. For liver transplantation, there remains an imbalance of about 35. Death on the renal transplant waiting list has been below 2% since 1993. Death on the liver transplant waiting list decreased from 10–20% in 1993–1995 to 3% in 1998. The number of children who died on the thoracic organ waiting list in 1998 was the same as the number transplanted. In conclusion, the new rules governing organ allocation to children in France have shortened waiting time for renal transplantation, but not for liver transplantation. Many children still die on the waiting list for thoracic organ transplantation. Received: 4 July 2001 / Revised: 4 October 2001 / Accepted: 4 October 2001     

Strategies for prevention and control of the 2019 novel coronavirus disease in the department of kidney transplantation

To summarize measures for the prevention and control of the 2019 novel coronavirus disease (COVID-19) in the department of kidney transplantation. We retrospectively analyzed the clinical data of outpatients and inpatients in the department of kidney transplantation from January 20 to March 1, 2020, and followed up the in-home kidney transplant recipients and those waiting for kidney transplantation through the Internet platform. Our department had formulated detailed prevention and control measures, mainly including kidney transplant outpatient management, kidney transplantation ward management, management of kidney transplant surgery, dialysis management of patients waiting for kidney transplantation, personal protection of medical staff, and follow-up management of discharged patients after kidney transplantation. During the epidemic period, there were no COVID-19 cases among 68 outpatient examined kidney transplant recipients, 32 hospitalized kidney transplant recipients, 19 patients waiting for kidney transplantation in hospital, and 30 medical staff. There were no COVID-19 cases among 160 follow-up recipients after kidney transplantation and 60 patients waiting for kidney transplantation. During the epidemic period, we implemented strict prevention and control measures and adjusted working methods and procedures to ensure safe and orderly work of the department.     

Live and Deceased Donor Kidney Transplantation in Patients Aged 75 years and Older in the United States

Objective: To examine the outcomes of geriatric ESRD patients selected for kidney transplantation. Design: Data were extracted from the USRDS Standard Analysis Files (SAF). All persons ages 75 and over who received a kidney transplant from 1994 to 2000 were compared with those remaining on dialysis or on a transplant waiting list. Data on mortality or removal from the waiting list were obtained from the United Network for Organ Sharing (UNOS). The main outcome measure was patient and kidney transplant survival. Results: Superior five year survival after kidney transplantation was attained by the geriatric cohort given a live donor transplant (59.9%), compared with recipients of deceased donor kidneys (40.3%), dialysis patients waiting for transplant (29.7%), and those who were not selected for kidney transplantation and remained on dialysis (12.5%). The likelihood of being removed from the waiting list for any reason was higher in this group (over 75) (30.3%) than in the 66–75 age group (26.8%). Their average annual mortality rate on the waiting list was 7.9, compared to 6.6% for those 66–75. Conclusion: Even after the age of 75 years, kidney transplantation provides substantial life prolongation and excellent graft survival. USRDS Disclaimer: The data reported here have been supplied by the United States Renal Data System (USRDS) and the United Network for Organ Sharing (UNOS). The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as official policy or interpretation of the US government.     

Between‐center disparities in access to heart transplantation in France: contribution of candidate and center factors — A comprehensive cohort study

Transplantation represents the last option for patients with advanced heart failure. We assessed between‐center disparities in access to heart transplantation in France 1 year after registration and evaluated the contribution of factors to these disparities. Adults (n = 2347) registered on the French national waiting list between January 1, 2010, and December 31, 2014, in the 23 transplant centers were included. Associations between candidate and transplant center characteristics and access to transplantation were assessed by proportional hazards frailty models. Candidate blood groups O and A, sensitization, and body mass index ≥30 kg/m² were independently associated with lower access to transplantation, while female gender, severity of heart failure, and high serum bilirubin levels were independently associated with greater access to transplantation. Center factors significantly associated with access to transplantation were heart donation rate in the donation service area, proportion of high‐urgency candidates among listed patients, and donor heart offer decline rate. Between‐center variability in access to transplantation increased by 5% after adjustment for candidate factors and decreased by 57% after adjustment for center factors. After adjustment for candidate and center factors, five centers were still outside of normal variability. These findings will be taken into account in the future French heart allocation system.