Backdating to Dialysis: Effects on Access and Policy Implications”

The donor kidney allocation process has been subject to review for several years with proposed new allocation rules expected to be implemented in 2014.  The new rules will include the time since the start of dialysis as an additional factor in the allocation process because longer dialysis time is associated with worse post-transplant outcomes (Schold et al., 2010)¹. In addition to potentially improving post-transplant outcomes by reducing dialysis time, including dialysis time might also improve access to transplantation among the socioeconomically disadvantaged. Keith et al. (2008)² find that insurance type, low educational attainment, and minority status increase the total time from the start of dialysis to the date of transplantation. The extent to which the new allocation rules may benefit the socioeconomically disadvantaged is unknown, although a pilot program replacing time since waitlisting with time since the start of dialysis has existed since 2006 and affects 26 transplant centers and approximately 10% of the waitlisted patient population. Preliminary results indicate that programs that switched from using the time since waitlisting to the time since the start of dialysis increased the probability of transplantation among African-Americans by 9%, Hispanics by 10%, those with at most a high school education by 7%, and those on public insurance programs by 15%. Because of the extreme disparity between the supply of organs and the demand for transplants, the total number of transplants is unlikely to change as a result of the proposed policy but is hypothesized to shift the distribution of patients towards those with more limited access. Unfortunately, this shift is likely to be associated with a reduction in survival rates due to the negative correlation between lower socioeconomic status and post-transplant survival, which extends beyond that explained by disparities in dialysis time. The results of this study regarding the effects of the pilot program on total life years will inform those establishing the new allocation rules of the tradeoffs between equity and efficiency in kidney transplantation.

¹Schold, J.D., A.R. Sehgal, T.R. Srinivas, E.D. Poggio, S.D. Navaneethan, and B. Kaplan. 2010. Marked Variation of the Association of ESRD Duration Before and After Wait Listing on Kidney Transplant Outcomes. American Journal of Transplantation, Vol. 10, No. 9, pp.2008-2016.

²Keith, D., V.B. Ashby, F.K. Port, and A.B. Leichtman. 2008. Insurance Type and Minority Status Associated with Large Disparities in Prelisting Dialysis among Candidates for Kidney Transplantation. Clinical Journal of the American Society of Nephrology, Vol. 3, No. 2, pp.463-470.