Fast-Track Evaluation Boosts Kidney Transplant Waitlist Access

A streamlined way to evaluate kidney transplant candidates boosted the chances of nabbing a spot on the waitlist, a nonrandomized clinical trial found.

Using the novel Kidney Transplant Fast Track (KTFT) evaluation approach, patients had a 40% higher likelihood of being placed on the active waitlist for kidney transplant compared with standard care after adjusting for demographic and clinical factors (subdistribution hazard ratio [SHR] 1.40, 95% CI 1.24-1.59), Larissa Myaskovsky, PhD, of the University of New Mexico Health Sciences Center in Albuquerque, and colleagues reported.

After getting a spot on the waitlist, patients in the fast-track group had a 21% (SHR 1.21, 95% CI 1.04-1.41) higher likelihood of receiving a kidney transplant than controls over a 7-year period.

What sets the fast-track approach apart is that patients complete most or all of their testing on the day of their first pre-transplant clinic appointment, the researchers explained in JAMA Internal Medicine.

The fast-track evaluation uses the same urgent, healthcare system-facilitated approach that exists for other end-organ transplants which “removes the complex coordination of care that patients must complete on their own for kidney transplant evaluation,” they added.

“Most patients referred for kidney transplant do not get a kidney transplant, in part because of the significant patient burden in navigating the kidney transplant evaluation process after a referral,” Myaskovsky and co-authors underscored.

“Kidney transplant evaluation traditionally requires an initial visit with the transplant team, a battery of tests conducted by multiple specialists, and several follow-up visits before a patient case is presented to the transplant team for a decision about waitlisting the patient for kidney transplant,” they wrote.

“Typically, patients must complete testing on their own and ensure that results are forwarded to the transplant team,” the researchers added. “The process is lengthy, time-consuming, and burdensome to the patient.”

The process can be particularly arduous on patients who feel sick, have low health literacy, or experience barriers in the healthcare system and can exacerbate long-standing racial, ethnic, and socioeconomic barriers to kidney transplant — the gold-standard treatment for end-stage kidney disease (ESKD).

The analysis included patients evaluated for kidney transplant at University of Pittsburgh Medical Center Starzl Transplantation Institute, one of the largest of 42 transplant centers in United Network for Organ Sharing Region 2. Evaluations were scheduled between May 2015 and June 2018, and patients were followed by electronic health records through August 2022. A total of 1,118 patients were included in the fast-track group (average age 57.2, 37.2% female) and 1,152 patients served as historical controls (average age 55.5, 38.8% female).

The fast-track approach “seems to have buffered a racial disparity in wait-listing,” Raegan Durant, MD, MPH, of the University of Alabama at Birmingham, pointed out in an accompanying editor’s note.

Compared with controls, both Black patients (SHR 1.54, 95% CI 1.11-2.14) and White patients (SHR 1.38, 95% CI 1.16-1.65) in the fast-track approach were more likely to be waitlisted. Waitlisted Black patients in the fast-track group were also significantly more likely to later undergo kidney transplant (SHR 1.52, 95% CI 1.06-2.16), though this difference wasn’t reported in white patients and other races or ethnicities.

“In bundling the evaluation steps on a single day, the KTFT intervention may exemplify an ideal component of future approaches to improve kidney transplant wait-listing while mitigating barriers disproportionately affecting Black patients with ESKD, older adults, and those with limited socioeconomic support,” Durant observed.

The findings are “particularly important because they are a substantial departure from previous interventions focused on patient education, which neither alleviated the logistical burden for patients nor were associated with improved waitlisting or kidney transplant outcomes,” the researchers noted.

“We believe that the KTFT intervention reduced patient burden and focuses on what the health care system can do for all patients regardless of their social determinants of health,” they wrote. “We believe that KTFT should be implemented as standard care across transplant centers to the greatest extent possible.”

The study was limited to only one “very well-resourced” transplant center, where most patients were well-insured, Myaskovsky and co-authors acknowledged. Future studies should evaluate this method in a wider range of healthcare settings, they suggested.

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