Study shows policy changes to kidney allocation may unintentionally reduce access to transplant to South Carolina

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MUSC Health

While the average time spent on a waitlist for a kidney transplant in South Carolina is 42 months, changes to the U.S. kidney allocation system could result in reduced access to kidney transplants and further time on waiting lists, according to a recent paper in JAMA Surgery.

“At face value, the changes in the allocation system seem quite appropriate,” said Derek DuBay (Medical University of South Carolina (MUSC), Charleston, USA), director of transplant at MUSC Health and principal investigator on the study. “Everyone waits in line for the same amount of time. It’s hard to argue with that.” And yet he still disagrees.

There are three main components to transplant volume: organ allocation, a particular transplant centre’s aggressiveness for accepting organs, and a patient’s geographical access to a transplant centre. The Organ Procurement and Transportation Network (OPTN) addressed allocation inequalities by ensuring that all patients wait at least the same amount of time for a kidney rather than the previous geography-based model.

However, as the only transplant centre in South Carolina, researchers had an opportunity to predict the results of these allocation changes, as MUSC Health performs more kidney transplants per year than any other organ transplant in its program.

As the gold standard for chronic renal failure treatment, a kidney transplant can add 5 years to a patient’s life expectancy, on average, compared to dialysis. DuBay’s team looked at patients with end-stage kidney disease (ESKD) for this study, since kidney transplant is the best treatment option for these patients.

DuBay and his research team aim to ensure equitable access to organ donations—the same goal as the OPTN. Recent results for ESKD patients, however, point to longer wait times for those in rural parts of the country than the times seen before the policy changes. With more Medicaid expansion programs in urban areas, higher rates of insurance and closer proximity to transplant centres, patients in densely populated areas have more access to donated organs even if their wait times are longer.

While ESKD patients in South Carolina wait 3.5 years on average for a kidney, patients in New York City can wait upwards of 8 years. And while that appears to be unfair at first glance, DuBay argues that with a higher population density and high access to organ donation, patients in New York City are 3 times more likely to receive an organ than those in South Carolina, despite the longer list.

DuBay compares the organ allocation equation to lines at a theme park. While it may appear that those in rural areas have a fast pass, he suggests the OPTN consider which patients to put on the list rather than the wait times of those already on the list.

“I think the important metric to consider is who gets into the theme park,” said DuBay. “If waiting times are equal length, equal proportions of people with renal failure from South Carolina and New York City should be admitted to the park. Alternatively, if we let three times more people from New York into the theme park, for instance, then maybe they should wait a little bit longer.”

Allocation can look like the right aspect to address, but DuBay points to access to transplant instead. “In South Carolina, we have been hit with a double whammy,” he said. “You have patients with renal failure and ESKD whose chances of getting on the waitlist are already low. And now with the new allocation system, if they do get on the waitlist, they have an even lower probability of getting a transplant than before.”

These policy changes are also predicted to result in a 40% decline in kidney transplant volumes for the state—not due to a shorter waitlist, but due to reduced access to transplant.

This research reflects the importance of this access when looking at transplant volumes. “Organ allocation algorithms cannot fix all of the inequities of organ transplantation,” said DuBay, “And in fact, they can unintentionally worsen it.” His goal is to bring public awareness and help his patients get the care they need.

“The average person in Sumter, South Carolina, should have the same opportunity and probability for a kidney transplant as those with renal failure in Chicago,” he said. “It should not be different because you have a different health care infrastructure or a different allocation system. The playing field needs to be levelled.”

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