Schold Jesse D, Mohan Sumit, Huml Anne, Buccini Laura D, Sedor John R, Augustine Joshua J, Poggio Emilio D
Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.
Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.
J Am Soc Nephrol. 2021 Apr;32(4):913-926. doi: 10.1681/ASN.2020060888. Epub 2021 Feb 11.
Extensive research and policies have been developed to improve access to kidney transplantation among patients with ESKD. Despite this, wide variation in transplant referral rates exists between dialysis facilities.
To evaluate the longitudinal pattern of access to kidney transplantation over the past two decades, we conducted a retrospective cohort study of adult patients with ESKD initiating ESKD or placed on a transplant waiting list from 1997 to 2016 in the United States Renal Data System. We used cumulative incidence models accounting for competing risks and multivariable Cox models to evaluate time to waiting list placement or transplantation (WLT) from ESKD onset.
Among the study population of 1,309,998 adult patients, cumulative 4-year WLT was 29.7%, which was unchanged over five eras. Preemptive WLT (prior to dialysis) increased by era (5.2% in 1997-2000 to 9.8% in 2013-2016), as did 4-year WLT incidence among patients aged 60-70 (13.4% in 1997-2000 to 19.8% in 2013-2016). Four-year WLT incidence diminished among patients aged 18-39 (55.8%-48.8%). Incidence of WLT was substantially lower among patients in lower-income communities, with no improvement over time. Likelihood of WLT after dialysis significantly declined over time (adjusted hazard ratio, 0.80; 95% confidence interval, 0.79 to 0.82) in 2013-2016 relative to 1997-2000.
Despite wide recognition, policy reforms, and extensive research, rates of WLT following ESKD onset did not seem to improve in more than two decades and were consistently reduced among vulnerable populations. Improving access to transplantation may require more substantial interventions.
为改善终末期肾病（ESKD）患者获得肾移植的机会，已经开展了广泛的研究并制定了相关政策。尽管如此，透析机构之间的移植转诊率仍存在很大差异。
为评估过去二十年来获得肾移植的纵向模式，我们对1997年至2016年在美国肾脏数据系统中开始接受ESKD治疗或被列入移植等待名单的成年ESKD患者进行了一项回顾性队列研究。我们使用考虑竞争风险的累积发病率模型和多变量Cox模型来评估从ESKD发病到列入等待名单或进行移植（WLT）的时间。
在1309998名成年患者的研究人群中，4年累积WLT为29.7%，在五个时期内没有变化。抢先WLT（透析前）随时期增加（1997 - 2000年为5.2%，2013 - 2016年为9.8%），60 - 70岁患者的4年WLT发病率也有所增加（1997 - 2000年为13.4%，2013 - 2016年为19.8%）。18 - 39岁患者的4年WLT发病率有所下降（55.8% - 48.8%）。低收入社区患者的WLT发病率显著较低，且随时间没有改善。与1997 - 2000年相比，2013 - 2016年透析后WLT的可能性显著下降（调整后风险比，0.80；95%置信区间，0.79至0.82）。
尽管得到广泛认可、进行了政策改革并开展了广泛研究，但ESKD发病后的WLT率在二十多年来似乎并未改善，弱势群体中的WLT率持续下降。改善移植机会可能需要更实质性的干预措施。
