Department of Nephrology and Hypertension, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio;
Division of Nephrology, Louis Stokes Veterans Administration Hospital, Cleveland, Ohio.
J Am Soc Nephrol. 2018 Oct;29(10):2574-2582. doi: 10.1681/ASN.2017111204. Epub 2018 Jul 13.
The process for evaluating kidney transplant candidates and applicable centers is distinct for patients with Veterans Administration (VA) coverage. We compared transplant rates between candidates on the kidney waiting list with VA coverage and those with other primary insurance.
Using the Scientific Registry of Transplant Recipients database, we obtained data for all adult patients in the United States listed for a primary solitary kidney transplant between January 2004 and August 2016. Of 302,457 patients analyzed, 3663 had VA primary insurance coverage.
VA patients had a much greater median distance to their transplant center than those with other insurance had (282 versus 22 miles). In an adjusted Cox model, compared with private pay and Medicare patients, VA patients had a hazard ratio (95% confidence interval) for time to transplant of 0.72 (0.68 to 0.76) and 0.85 (0.81 to 0.90), respectively, and lower rates for living and deceased donor transplants. In a model comparing VA transplant rates with rates from four local non-VA competing centers in the same donor service areas, lower transplant rates for VA patients than for privately insured patients persisted (hazard ratio, 0.72; 95% confidence interval, 0.65 to 0.79) despite similar adjusted mortality rates. Transplant rates for VA patients were similar to those of Medicare patients locally, although Medicare patients were more likely to die or be delisted after waitlist placement.
After successful listing, VA kidney transplant candidates appear to have persistent barriers to transplant. Further contemporary analyses are needed to account for variables that contribute to such differential transplant rates.
评估肾移植候选人及适用中心的流程在有退伍军人事务部（VA）保险的患者中是独特的。我们比较了有 VA 保险和其他主要保险的候选人在肾脏等待名单上的移植率。
使用移植受者科学登记处数据库，我们获取了 2004 年 1 月至 2016 年 8 月期间美国所有接受主要单肾移植的成年患者的数据。在分析的 302457 名患者中，有 3663 名患者有 VA 主要保险。
VA 患者到移植中心的中位数距离比其他保险患者远得多（282 英里对 22 英里）。在调整后的 Cox 模型中，与私人支付和医疗保险患者相比，VA 患者接受移植的时间风险比（95%置信区间）分别为 0.72（0.68 至 0.76）和 0.85（0.81 至 0.90），并且活体和已故供体移植的比例较低。在一个比较 VA 移植率与同一供体服务区四个当地非 VA 竞争中心的模型中，VA 患者的移植率低于私人保险患者的比例仍然存在（风险比，0.72；95%置信区间，0.65 至 0.79），尽管调整后的死亡率相似。VA 患者的移植率与医疗保险患者相似，但医疗保险患者在等待名单上放置后更有可能死亡或被除名。
成功列入名单后，VA 肾移植候选人似乎仍然存在移植的障碍。需要进一步进行当代分析，以解释导致这种差异移植率的变量。
