Department of Pediatrics, Division of Nephrology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Department of Nephrology, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois.
Clin J Am Soc Nephrol. 2021 Dec;16(12):1862-1871. doi: 10.2215/CJN.06740521. Epub 2021 Oct 20.
In December 2014, the Kidney Allocation System (KAS) was implemented to improve equity in access to transplantation, but preliminary studies in children show mixed results. Thus, we aimed to assess how the 2014 KAS policy change affected racial and ethnic disparities in pediatric kidney transplantation access and related outcomes.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We performed a retrospective cohort study of children <18 years of age active on the kidney transplant list from 2008 to 2019 using the Scientific Registry of Transplant Recipients. Log-logistic accelerated failure time models were used to determine the time from first activation on the transplant list and the time on dialysis to deceased donor transplant, each with KAS era or race and ethnicity as the exposure of interest. We used logistic regression to assess odds of delayed graft function. Log-rank tests assessed time to graft loss within racial and ethnic groups across KAS eras.
All children experienced longer wait times from activation to transplantation post-KAS. In univariable analysis, Black and Hispanic children and other children of color experienced longer times from activation to transplant compared with White children in both eras; this finding was largely attenuated after multivariable analysis (time ratio, 1.16; 95% confidence interval, 1.01 to 1.32; time ratio, 1.13; 95% confidence interval, 1.00 to 1.28; and time ratio, 1.17; 95% confidence interval, 0.96 to 1.41 post-KAS, respectively). Multivariable analysis also showed that racial and ethnic disparities in time from dialysis initiation to transplantation in the pre-KAS era were mitigated in the post-KAS era. There were no disparities in odds of delayed graft function. Black and Hispanic children experienced longer times with a functioning graft in the post-KAS era.
No racial and ethnic disparities from activation to deceased donor transplantation were seen before or after implementation of the KAS in multivariable analysis, whereas time on dialysis to transplantation and odds of short-term graft loss improved in equity after the implementation of the KAS, without compromising disparities in delayed graft function.
This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_12_07_CJN06740521.mp3.
2014 年 12 月，实施了肾脏分配系统（KAS）以改善移植机会的公平性，但对儿童的初步研究结果喜忧参半。因此，我们旨在评估 2014 年 KAS 政策变化如何影响儿科肾脏移植机会获取和相关结局的种族和民族差异。
设计、地点、参与者和测量：我们使用 Scientific Registry of Transplant Recipients 进行了一项回顾性队列研究，纳入了 2008 年至 2019 年期间年龄在 18 岁以下且活跃在肾脏移植名单上的儿童。对数-对数加速失效时间模型用于确定从移植名单上首次激活到接受已故供体移植的时间，以及在 KAS 时代或种族和民族作为感兴趣的暴露因素时进行透析的时间。我们使用逻辑回归评估延迟移植物功能障碍的可能性。对数秩检验评估了 KAS 时代内不同种族和民族群体的移植物丢失时间。
所有儿童在 KAS 后从激活到移植的等待时间都更长。在单变量分析中，与白人儿童相比，黑人、西班牙裔和其他有色人种儿童在两个时代的从激活到移植的时间都更长；多变量分析后，这一发现基本减弱（时间比，1.16；95%置信区间，1.01 至 1.32；时间比，1.13；95%置信区间，1.00 至 1.28；时间比，1.17；95%置信区间，0.96 至 1.41，分别）。多变量分析还表明，在 KAS 前时代，从开始透析到移植的时间种族和民族差异在 KAS 后时代得到缓解。在延迟移植物功能障碍方面，没有出现种族和民族差异的可能性。黑人儿童和西班牙裔儿童在 KAS 后时代经历了更长的有功能移植物的时间。
在多变量分析中，KAS 实施前后，从激活到已故供体移植都没有出现种族和民族差异，而在 KAS 实施后，透析到移植的时间和短期移植物丢失的可能性在公平性方面得到改善，而不会损害延迟移植物功能障碍方面的差异。
本文包含一个播客，网址为 https://www.asn-online.org/media/podcast/CJASN/2021_12_07_CJN06740521.mp3。
