美国肾移植中等待时间的地域差异的程度和预测因素。
The extent and predictors of waiting time geographic disparity in kidney transplantation in the United States.
机构信息
1 Industrial Engineering and Management Sciences, Northwestern University, Evanston, IL. 2 Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL. 3 Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University, Chicago, IL. 4 Center for Engineering and Health, Northwestern University, Chicago, IL. 5 Division of Nephrology, Department of Medicine, Feinberg School of Medicine, Chicago, IL. 6 Address correspondence to: Daniela P. Ladner, M.D., M.P.H., Surgery, Division of Transplantation, Department of Surgery Director Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC) Feinberg School of Medicine, Northwestern University 676 N. St. Clair Street, Suite 1900 Chicago, IL 60611.
出版信息
Transplantation. 2014 May 27;97(10):1049-57. doi: 10.1097/01.tp.0000438623.89310.dc.
BACKGROUND
Waiting time to deceased donor kidney transplant varies greatly across the United States. This variation violates the final rule, a federal mandate, which demands geographic equity in organ allocation for transplantation.
METHODS
Retrospective analysis of the United States Renal Data System and United Network for Organ Sharing database from 2000 to 2009. Median waiting time was calculated for each of the 58 donor service areas (DSA) in the United States. Multivariate regression was performed to identify DSA predictors for long waiting times to kidney transplantation.
RESULTS
The median waiting time varied between the 58 DSAs from 0.61 to 4.57 years, ranging from 0.59 to 5.17 years for standard criteria donor kidneys and 0.41 to 4.69 years for expanded criteria donor kidneys. The disparity in waiting time between the DSAs grew from 3.26 years (range, 0.41-3.67) in 2000 to 4.72 years (range, 0.50-5.22) in 2009. In DSAs with longer waiting times, there were significantly more patients suffering from end-stage renal disease and more patients listed for kidney transplant, lower kidney procurement rates, and higher transplant center competition. Patients were more likely black, sensitized, with lower educational attainment and less likely to waitlist outside of their DSA of residence. Donor organs used in DSAs with long waiting times were more likely hepatitis C positive and had a higher kidney donor profile index. Graft and patient survival at 5 years was worse for deceased donor kidney transplant, but rates for living donor kidney transplant were higher.
CONCLUSION
Our analysis demonstrates significant and worsening geographic disparity in waiting time for kidney transplant across the DSAs. Increase in living donor kidney transplant and use of marginal organs has not mitigated the disparity. Changes to the kidney allocation system might be required to resolve this extensive geographic disparity in kidney allocation.
背景
在美国，等待已故供体肾移植的时间差异很大。这种差异违反了最终规定，即联邦授权，要求在器官分配方面实现移植的地理公平。
方法
对 2000 年至 2009 年美国肾脏数据系统和联合器官共享网络数据库进行回顾性分析。计算了美国 58 个供体服务区域（DSA）的中位数等待时间。进行多变量回归以确定导致肾脏移植等待时间延长的 DSA 预测因素。
结果
58 个 DSA 的中位数等待时间从 0.61 到 4.57 年不等，标准标准供体肾脏的范围为 0.59 到 5.17 年，扩展标准供体肾脏的范围为 0.41 到 4.69 年。2000 年至 2009 年，DSA 之间的等待时间差距从 3.26 年（范围为 0.41-3.67）扩大到 4.72 年（范围为 0.50-5.22）。在等待时间较长的 DSA 中，患有终末期肾病的患者和等待肾移植的患者明显更多，肾脏获取率较低，移植中心竞争更激烈。患者更有可能是黑人、致敏、受教育程度较低，且不太可能在居住地以外的 DSA 登记。在等待时间较长的 DSA 中使用的供体器官更有可能是丙型肝炎阳性，且肾脏供体指数更高。5 年时，已故供体肾移植的移植物和患者存活率较差，但活体供体肾移植的比例更高。
结论
我们的分析表明，DSA 之间的肾脏移植等待时间存在显著且不断加剧的地理差异。增加活体供体肾移植和使用边缘器官并没有减轻这种差异。可能需要对肾脏分配系统进行更改，以解决这种广泛的肾脏分配地理差异。
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