Implementation of the 2014 kidney allocation system led to increase in kidney transplantation referrals

Reviewed by Emily Henderson, B.Sc.Mar 14 2022

A study of patients initiating dialysis during 2012-2016 at nine transplant centers in the Southeastern US found that dialysis facilities referred more incident patients and transplant centers evaluated more incident patients following implementation of the 2014 kidney allocation system (KAS) but fewer evaluated patients were placed onto the waitlist. Changes in dialysis facility and transplant center behaviors following implementation of the 2014 KAS may have influenced access to transplantation.

Nationally, waitlisting has declined following implementation of the 2014 change in the kidney allocation system (KAS). This study led by Dr Rachel Patzer (Emory University) sought to examine whether this decrease in waitlisting was driven by lower rates of referral, evaluation, or waitlisting in the Southeastern US, the only region with systematic data collection on early transplant steps that would facilitate this analysis. Results from this region encompassing Georgia, North Carolina, and South Carolina suggest that among the incident population that started the evaluation process, KAS led to a decline in overall waitlisting.

Dialysis facilities referred more incident patients and transplant centers evaluated more incident patients following implementation of KAS but fewer evaluated patients were placed onto the waitlist. Overall, the effect of KAS differed by transplant step and by incident vs. prevalent dialysis patients, and overall, declines in waitlisting observed in the post-KAS era are largely due to decreased transplant center waitlisting of referred patients.

These findings suggest that the change in KAS policy likely influenced provider behavior both at dialysis facilities (with respect to transplant referrals) as well as transplant programs (e.g., evaluation and waitlisting practices). This study, published in the American Journal of Kidney Diseases (AJKD), offers context for why overall waitlisting rates have declined nationally since the implementation of the 2014 KAS change and underscores the need to collect surveillance data on these important pre-waitlisting process measures nationally, particularly as new changes in kidney allocation and new quality measures in dialysis facilities and transplant programs are under development.