Faculty Bibliography

BACKGROUND:Patients with kidney failure require treatments that are demanding and time-intensive, potentially interfering with employability and leading to indirect costs. We sought to characterize the prevalence of, and risk factors for financial toxicity among patients with kidney failure. METHODS:We conducted a cross-sectional survey study of 112 participants with kidney failure at a large, urban, academic medical center. Financial toxicity was assessed via a survey which included the validated CoST tool as well as additional items to evaluate self-reported changes to material conditions and financial coping behaviors. Participants were grouped according to kidney replacement therapy modality (dialysis, transplant after dialysis, or preemptive transplant) Descriptive statistics were used to summarize demographic and clinical characteristics of the study population and to compare those with above-median vs below-medial CoST scores, and by modality of kidney replacement therapy. RESULTS:Median CoST score was 17 with 71% of participants experiencing at least mild financial toxicity. Participants experiencing financial toxicity were less likely to have White race, and more likely to be receiving dialysis. Over half of participants reported reduction in employment (61%) or income (57%) following kidney failure onset with the greatest likelihood of these among participants with any dialysis. CONCLUSIONS:Adults with kidney failure experience significant financial toxicity as measured by the CoST score and report significant negative changes in employment and income. Although this toxicity persists through many stages of treatment, treatment modality may impact financial burdens experienced by patients with kidney failure.

Out-of-sequence (OOS) kidney allocation has become increasingly prevalent since 2021. We examined the relationship between organ procurement organization (OPO) OOS allocation frequency and kidney nonuse rates. Among 57 OPOs between March 2021 and December 2023, we analyzed trends in OOS utilization and its association with kidney nonuse rates. There was significant variability in OOS use across OPOs, with some allocating over 20% of kidneys out-of-sequence over the entire period. An absolute increase of 1 SD (12.8%) of OOS allocation was modestly associated with a reduction in kidney nonuse rates (incidence risk ratio = 0.98; P = .04). Donor characteristics, particularly older age, donation after circulatory death, and high kidney donor profile index, were the strongest predictors of nonuse. While OOS allocation may mitigate logistical challenges, other strategies may be more effective at reducing the nonuse rate.

On March 9, 2023, allocation of donor lungs in the United States changed to continuous distribution (CD). Initial implementation of policy was flawed due to a programming error affecting priority of candidates by blood type. Although this issue has been identified and addressed, the impact of initial policy implementation on blood type-O candidates has not been rigorously evaluated. We used data from the Scientific Registry of Transplant Recipients to evaluate candidate (n = 4738) and recipient (n = 4437) outcomes following CD policy implementation. Using cumulative incidence plots accounting for competing risks and multivariable Cox models, incidence of transplantation prepolicy was similar by blood type (8-month incidence 81.0% vs 80.5% for blood types-A, B, or AB and blood type-O, respectively, P = .57). Following CD policy, blood type-O candidates had lower incidence of transplantation relative to other blood types (8-month incidences 86.3% vs 92.1%, respectively, P < .001), with a significantly lower adjusted hazard ratio for transplantation (0.67; 95% confidence interval, 0.54-0.82). Blood type-O candidates were more likely Hispanic and 'Other' race and had higher rates of waitlist removal or death following CD (6.0% vs 2.9%, P = .003). Among transplants performed prior to CD, 48% were blood type-O recipients compared to 40% post-CD, representing 138 fewer blood type-O transplants than expected. Type-O blood candidates had significant decline in prognosis relative to other blood groups following initial implementation of CD policy.

Organ Procurement Organizations (OPOs) recover deceased donor kidneys and place them with matched recipients according to ranked match runs of patients, but offer notification practices differ across the OPOs and have changed following updates to allocation policy (kidney allocation system 250 [KAS250]). This national registry study used batch notification data to quantify time spent on kidney allocation and identify variations in batch notification practices across OPOs before and after the KAS250 allocation system era. Overall allocation time between the first and last offer notifications increased from a median of 1 to 7 hours under the KAS250 allocation system. For match runs of unplaced kidneys, allocation time increased from a median of 18 to 28 hours. Out-of-sequence (OOS) allocation, used by OPOs to limit nonutilization due to excess cold ischemia time, more than doubled in frequency between 2018 and 2022, with median time from first offer to initiation of OOS varying across OPOs from 0 to 47 hours. Increasing rates of organ nonutilization and the observed allocation practice differences based on organ quality demonstrate the urgent need for new approaches to achieve more efficient placement of hard-to-place kidneys. Data-driven approaches to optimize kidney allocation efforts will help ensure fairness in a system that currently allows for wide practice variation and frequent OOS allocation.

Out-of-sequence (OOS) allocation, the process by which organ procurement organizations (OPOs) can deviate from standard rank lists of potential recipients to expeditiously allocate deceased-donor kidneys, is increasing in the United States. We aimed to determine whether current OPO reporting practices obscure the extent of OOS allocation. Using match-run data for all US deceased-donor kidney transplants from 2021-2023, we defined miscoded OOS (mOOS) allocation transplants as those with use of the 799 or 898 OPO-initiated refusal codes (other, specify) with free-text responses clearly indicating OOS allocation and compared them with explicit OOS allocation, in which OOS transplants are appropriately coded using refusal codes 861 to 863. We found that the prevalence of mOOS allocation increased from 2021 (122 transplants) to 2023 (430 transplants) and accounted for 12% of all OOS transplants by 2023. Organs allocated via mOOS had a lower median kidney donor profile index than those allocated via explicit OOS (51% vs 55%, P < .01). While an increasing number of OPOs used mOOS throughout the study period, the practice remained concentrated overall, with 5 high-frequency OPOs performing 66% of mOOS allocations in 2023. These findings highlight the need for stricter oversight of organ allocation and underscore the responsibility of the Organ Procurement and Transplant Network to ensure proper data reporting.

PURPOSE OF REVIEW/OBJECTIVE:Demonstrate the impact of allocation system design on access to the waitlist and transplantation for patients with end-stage kidney disease (ESKD). RECENT FINDINGS/RESULTS:Minoritized groups are more likely to be declined from transplant listing owing to psychosocial criteria. Lack of consistent definitions, screening tools with differential subgroup validity, and insufficient evidence-base contribute to concerns about reliance on psychosocial factors in transplant listing decisions. SUMMARY/CONCLUSIONS:Although kidney transplantation is the preferred treatment choice, a shrinking proportion of prevalent patients are waitlisted for this option in the United States, even among our youngest ESKD patients. Recent HRSA proposals to expand data collection to encompass the prewaitlisting process suggest a timely need to capture additional data on transplant referrals to improve access to transplantation. In 2021, KAS250 was implemented in response to concerns of geographic inequities in transplant rates. However, updates to this system have also resulted in a dramatic rise in organ offers, the number of offers needed to successfully place an organ and lowered utilization rates. Since KAS250, the use of alternative pathways to improve organ utilization rates, such as out-of-sequence placements has increased dramatically across the organ quality spectrum and risk exacerbating disparities in access to transplant. Additionally, the current absence of meaningful oversight risks undermining the perception of the transplant system as an objective process. SUMMARY/CONCLUSIONS:There is a need for a more robust evaluation of recent iterative changes in waitlist and organ allocation practices to ensure equity in access for our most vulnerable patients.

INTRODUCTION/UNASSIGNED:In the United States (US), disparities in access to kidney transplantation exist for waitlisted candidates with end-stage kidney disease. Meanwhile, changes in kidney allocation policy have been associated with a dramatic increase in the number of organ offers declined before an organ is successfully placed. METHODS/UNASSIGNED:We describe transplant and mortality rates for waitlisted candidates from 2015 to 2022 following these allocation changes. RESULTS/UNASSIGNED:Among 249,145 incident waitlisted adults, 180,039 received at least 1 offer and were included in the study. Of these, 37.7% received a deceased donor kidney allograft, 14.7% received a living donor allograft, 7.4% died while on the waiting list, 12.7% were removed, and 27.5% were still waitlisted by the study end period. Overall, candidates' median number of days to receiving their first offer declined from 20 (7-48) in 2015 to 5 (2-13) in 2022. Candidates who died while on the waiting list received a median of 25 (9-56) offers and candidates who were removed received a median of 22 (8-53) offers during the study period. The total number of offers generated by the match-run algorithm, including those from nonutilized kidneys, increased sharply from 7,911,688 offers in 2015 to 13,682,914 in 2019, and to 29,332,516 in 2022. CONCLUSION/UNASSIGNED:These findings emphasize the inefficiencies inherent in our current allocation algorithms and the need to rethink how waitlisted patients are prioritized for a given deceased donor organ in order to maximize the probability of appropriate utilization of lifesaving organs .

INTRODUCTION/UNASSIGNED:In the United States (US), deceased donor kidney offers are most commonly declined by transplant centers on behalf of waitlisted candidates, without notifying them. We sought to understand patient and provider attitudes toward patient-facing organ offer reporting. METHODS/UNASSIGNED:We conducted a cross-sectional survey of patients, nephrologists, and nephrology social workers on the National Kidney Foundation mailing list and the medical and surgical directors of US kidney transplant programs. RESULTS/UNASSIGNED:Among 755 patient respondents, 64% wanted to receive organ offer reports. Patients who wanted organ offer information were younger, more likely to be of a non-White race, and more likely to be on dialysis or on the waiting list. Of the patients, 87% reported that centers should be required to tell candidates about the offers they receive, and 62% reported that candidates should be informed after every offer. Among the 107 nephrology respondents, 73% reported that candidates should be provided with organ offer information and 88% reported that they would want to receive a copy of their patients' offer reports. Among 26 transplant program director respondents, 77% reported that candidates should not be notified of offers declined on their behalf. If organ offer reports were required, most program director respondents believed that they should include the reasons offers were declined and should not include offers for kidneys that were ultimately discarded. CONCLUSIONS/UNASSIGNED:Most patients and nephrology providers, but only a minority of transplant program directors, supported the sharing of patient-facing information about individual deceased donor kidney offers that were declined on candidates' behalf.