Faculty Bibliography

Approximately 9% of deceased kidney donors are classified by the Centers for Disease Control as high infectious risk donors (HRDs), donors thought to be at increased risk for having HIV infection. While the use of HRDs expands the organ supply, there is a small risk of infectious transmission. All donors are tested for antibodies to a variety of viral infections including HIV, hepatitis C virus (HCV), and hepatitis B virus; however, infections acquired in the weeks to months before death may not be serologically detectable, but will likely be transmitted to the recipient. Nucleic acid testing (NAT) shortens the window between acquisition of infection and serologic detectability, from approximately 22 days to 9 days for HIV and from 66 days to 7 days for HCV. Nucleic acid testing has not been universally adopted because it is expensive, time consuming, and has a higher rate of false positives compared with an enzyme-linked immunosorbent assay (ELISA), which might lead to discarding viable organs. Further studies are needed to quantify the risk of infectious transmission from HRDs, identify patients on the waitlist who would most benefit from HRD receipt, and guide NAT policies.

In the setting of disparities in access to simultaneous pancreas and kidney transplantation (SPKT), Medicare coverage for this procedure was initiated July 1999. The impact of this change has not yet been studied. A national cohort of 22 190 type 1 diabetic candidates aged 18-55 for kidney transplantation (KT) alone or SPKT was analyzed. Before Medicare coverage, 57% of Caucasian, 36% of African American and 38% of Hispanic type 1 diabetics were registered for SPKT versus KT alone. After Medicare coverage, these proportions increased to 68%, 45% and 43%, respectively. The overall increase in SPKT registration rate was 27% (95% CI 1.16-1.38). As expected, the increase was more substantial in patients with Medicare primary insurance than those with private insurance (Relative Rate 1.18, 95% CI 1.09-1.28). However, racial disparities were unaffected by this policy change (African American vs. Caucasian: 0.97, 95% CI 0.87-1.09; Hispanic vs. Caucasian: 0.94, 95% CI 0.78-1.05). Even after Medicare coverage, African Americans and Hispanics had almost 30% lower SPKT registration rates than their Caucasian counterparts (95% CI 0.66-0.79 and 0.59-0.80, respectively). Medicare coverage for SPKT succeeded in increasing access for patients with Medicare, but did not affect the substantial racial disparities in access to this procedure.