Geographic Determinants of Access to Pediatric Deceased Donor Kidney Transplanta

[Clark]

http://jasn.asnjournals.org/content/early/2014/01/15/ASN.2013070684.abstract

Geographic Determinants of Access to Pediatric Deceased Donor Kidney Transplantation
Peter P. Reese*†‡, Hojun Hwang†, Vishnu Potluri†, Peter L. Abt§, Justine Shults† and Sandra Amaral†‖
Published online before print January 16, 2014, doi: 10.1681/ASN.2013070684
JASN January 16, 2014 ASN.2013070684

Abstract

Children receive priority in the allocation of deceased donor kidneys for transplantation in the United States, but because allocation begins locally, geographic differences in population and organ supply may enable variation in pediatric access to transplantation. We assembled a cohort of 3764 individual listings for pediatric kidney transplantation in 2005–2010. For each donor service area, we assigned a category of short (<180 days), medium (181–270 days), or long (>270 days) median waiting time and calculated the ratio of pediatric-quality kidneys to pediatric candidates and the percentage of these kidneys locally diverted to adults. We used multivariable Cox regression analyses to examine the association between donor service area characteristics and time to deceased donor kidney transplantation. The Kaplan–Meier estimate of median waiting time to transplantation was 284 days (95% confidence interval, 263 to 300 days) and varied from 14 to 1313 days across donor service areas. Overall, 29% of pediatric-quality kidneys were locally diverted to adults. Compared with areas with short waiting times, areas with long waiting times had a lower ratio of pediatric-quality kidneys to candidates (3.1 versus 5.9; P<0.001) and more diversions to adults (31% versus 27%; P<0.001). In multivariable regression, a lower kidney to candidate ratio remained associated with longer waiting time (hazard ratio, 0.56 for areas with <2:1 versus reference areas with ≥5:1 kidneys/candidates; P<0.01). Large geographic variation in waiting time for pediatric deceased donor kidney transplantation exists and is highly associated with local supply and demand factors. Future organ allocation policy should address this geographic inequity.

[Clark]

  The mean "varied from 14 to 1313 days." Two weeks to nearly four years, on average, for kids in whole donor service areas. DSA boundaries and the limitations of sharing across them are among the greatest challenges facing us as we continue to move closer to balancing equity, justice, and utility in deceased donor organ allocation. The legacy of tiny geographic sharing areas from the dawn of transplantation practice is not serving us decades later. Broader sharing is coming, with nationwide allocation a greater possibility than ever with the new kidney allocation system.

  Broader liver and heart sharing has been in progress for years. The direct mail campaign to OPTN/UNOS board members by transplant centers in "supply" DSAs was an education in itself, as they argued that this was zero sum and they would be the losers. No investment in commercial appeals for broader sharing were necessary. The inequity of the huge difference in wait time between Manhattan and its neighbors, one among many, many possible examples, is clear. Solutions are difficult, as they involve change, and money, and entrenched vested interests. Even so, progress is being made. This article highlights why progress must continue.