Non-kidney transplant patients likely to undergo kidney transplant prior to dialysis: Study

Individuals who received a non-kidney organ transplant in the past may be more likely to be listed for a kidney transplant prior to initiation of dialysis (pre-emptive listing) than other candidates, according to a study appearing in an upcoming issue of the Clinical Journal of the American Society Nephrology (CJASN). The results indicate that the growth in the numbers of this group of kidney transplant candidates adds to the list of organ allocation challenges.

Kidney failure may accompany or complicate transplantation of the liver, heart, or lung. Because increasing numbers of individuals are receiving non-kidney transplants, researchers have wondered whether more of such patients are being listed for kidney transplants.

Titte Srinivas, MD (Cleveland Clinic) and his colleagues examined data from 1995 to 2008 from the national SRTR (Scientific Registry of Renal Transplant Recipients), and found a total of 4904 individuals who had had a prior organ transplant were waitlisted to receive a kidney transplant during this time period. Prior to 1995, less than 1% of people who had received other organ transplants were placed on kidney transplant waiting lists; in 2008, 3.3% of those who had received other organ transplants were waitlisted for kidney transplants.

The researchers found among individuals who had a prior organ transplant, 38% were waitlisted to receive a kidney transplant before initiating dialysis, compared with 21% of individuals who had not received a prior organ transplant. "Pre-emptive transplantation of a kidney (prior to dialysis) and listing for such is the preferred modality of management of end-stage kidney disease. This modality is especially relevant in the non-renal transplant population as they have much higher waitlist mortality than those with prior renal transplants. However, the more frequent pre-emptive transplants occurring in these patients may be a product of these patients and their caregivers being more familiar with navigating transplant procedures, and thus receiving superior pre-transplant care" said Dr. Srinivas. The impact of how physician advocacy plays a role needs investigation as well.

Compared with patients on kidney transplant waiting lists who had received a prior kidney transplant, waitlisted patients who had received a prior heart, liver, or lung transplant had a shorter lifespan. The authors recommend selectively targeting such patients for extended criteria donor kidneys, shortening wait time, considering living donor kidney transplants more often in these cases. "According to the authors, researchers should design studies that address practice and policy to include critical factors related to prior organ transplant and to ensure equitable allocation of resources and access to best practices among all kidney transplant candidates.

Study co-authors include Brian Stephany, MD, Marie Budev, DO, David Mason, MD, Charles Miller, MD, Randall Starling, MD, David Goldfarb, MD, Emilio Poggio, MD, Stuart Flechner, MD, and Jesse Schold, PhD (Cleveland Clinic).

Disclosures: The authors reported no financial disclosures.

The article, entitled "An Emerging Population: Kidney Transplant Candidates Who Are Placed on the Waiting List after Liver, Heart, and Lung Transplantation," will appear online at http://cjasn.asnjournals.org/ on September 2, 2010, doi 10.2215/CJN.02950410.