Association of the Affordable Care Act on Access to and Outcomes After Kidney or Liver Transplant: A Transplant Registry Study

Impact of public versus non public insurance on hispanic kidney transplant outcomes using UNOS database

Disparities in access to care and transplantation outcomes, including prolonged waitlist times and reduced living donor transplantation rates, are well-documented in Hispanic kidney transplant patients. While post-transplant graft and patient survival rates are generally comparable to those of non-Hispanic white patients, variability within the Hispanic population is driven by socioeconomic and clinical factors. Insurance type may be a crucial determinant of both access to transplantation and post-transplantation outcomes, warranting a focused study of its impact within this population. We used the OPTN/UNOS database to identify Hispanic kidney-only transplant recipients in the United States between 2015 and 2019. We categorized patients by insurance type to public versus non-public insurance. We compared risk of graft failure and death after kidney transplant between the public and non-public insurance groups. Of 14,639 Hispanic kidney transplant recipients, 10,761 (74%) had public insurance. Public insurance group were older, had more kidney retransplant, more deceased donor but less preemptive kidney transplant, longer dialysis duration, more diabetes, peripheral vascular disease, reduced functional status, and were less likely to be employed or have high education level compared to non-public insurance group. Public insurance was significantly associated with an increased risk of death-censored graft failure (HR 1.36; 95% CI 1.16-1.60) and patient death (HR 1.15; 95% CI 1.01-1.30). Similarly, public insurance was significantly associated with an increased risk of graft failure when accounting for death as the competing risk. Disparities in post-transplant outcomes were observed between Hispanic kidney recipients with public versus non-public insurance. Public insurance was a significant predictor for reduced graft and patient survival after kidney transplant.

Outcomes of Liver Transplant for Hepatic Epithelioid Hemangioendothelioma

INTRODUCTION

Hepatic epithelioid hemangioendothelioma (HEH) is a rare indication of liver transplant with limited evidence.

METHODS

Adult recipients undergoing first-time liver-only transplant from 2002 to 2021 in the United States were identified using the UNOS/OPTN database. We compared post-transplant outcomes of recipients receiving liver transplant for HEH versus other diagnoses. Survival was visualized using Kaplan-Meier curves and compared using log-rank test and multivariable Cox regression. Propensity score matching for recipient age, sex, and MELD was performed, with baseline characteristics and survival compared between groups.

RESULTS

Of 111 558 liver transplant recipients identified, 121 (0.1%) underwent transplant for HEH. Donors to HEH recipients were more often living donors. Recipients with HEH were younger, more likely to be female, and had lower BMI. Recipients with HEH had higher albumin, lower bilirubin, lower INR, and lower serum creatinine, as well as lower MELD scores and rates of ascites and encephalopathy. Similar post-transplant survival was observed for recipients with HEH (16.6 [lower 95% CI 14.9] years) and non-HEH diagnoses (13.8 [95% CI 13.6-13.9] years, log-rank p = 0.28), even after adjusting for baseline donor and recipient characteristics (aHR 1.28 [95% CI 0.94-1.74], p = 0.12). The propensity score matched cohort also had similar post-LT survival.

CONCLUSIONS

This national study represents the largest known report on liver transplant for HEH. The survival of recipients with HEH was similar to other etiologies, supporting the use of liver transplantation (LT) in advanced HEH.

Impact of Medicaid expansion on kidney transplantation in the State Oklahoma

BACKGROUND

There is no data evaluating the impact of Medicaid expansion on kidney transplants (KT) in Oklahoma.

AIM

To investigate the impact of Medicaid expansion on KT patients in Oklahoma.

METHODS

The UNOS database was utilized to evaluate data pertaining to adult KT recipients in Oklahoma in the pre-and post-Medicaid eras. Bivariate analysis, Kaplan Meier analysis was used to estimate, and cox proportional models were utilized.

RESULTS

There were 2758 pre- and 141 recipients in the post-Medicaid expansion era. Post-expansion patients were more often non-United States citizens (2.3% vs 5.7%), American Indian, Alaskan, or Pacific Islander (7.8% vs 9.2%), Hispanic (7.4% vs 12.8%), or Asian (2.5% vs 8.5%) (P < 0.0001). Waitlist time was shorter in the post-expansion era (410 vs 253 d) (P = 0.0011). Living donor rates, pre-emptive transplants, re-do transplants, delayed graft function rates, kidney donor profile index values, panel reactive antibodies levels, and insurance types were similar. Patients with public insurance were more frail. Despite increased early (< 6 months) rejection rates, 1-year patient and graft survival were similar. In Cox proportional hazards model, male sex, American Indian, Alaskan or Pacific Islander race, public insurance, and frailty category were independent risk factors for death at 1 year. Medicaid expansion was not associated with graft failure or patient survival (adjusted hazard ratio: 1.07; 95%CI: 0.26-4.41).

CONCLUSION

Medicaid expansion in Oklahoma is associated with increased KT access for non-White/non-Black and non-United States citizen patients with shorter wait times. 1-year graft and patient survival rates were similar before and after expansion. Medicaid expansion itself was not independently associated with graft or patient survival outcomes. Ongoing research is necessary to determine the long-term effects of Medicaid expansion.

Impact of the Kidney Allocation Revision on Access to Kidney Transplantation and Outcomes in the United States

BACKGROUND

The 2014 Kidney Allocation System (KAS) revision aimed to enhance equity in organ allocation and improve patient outcomes. This study assesses the impacts of the KAS revision on renal transplantation demographics and outcomes in the United States.

METHODS

We conducted a retrospective study utilizing the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients (OPTN/SRTR) database from 1998 to 2022. We compared recipient and donor characteristics, and outcomes (graft failure and recipient survival) pre- and post-KAS revision.

RESULTS

Post-KAS, recipients were significantly older (53 vs 48, P < .001) with an increase in Medicaid beneficiaries (7.3% vs 5.5%, P < .001). Despite increased graft survival, HR = .91 (95% CI 0.80-.92, P < .001), overall recipient survival decreased, HR = 1.06 (95% CI 1.04-1.09, P < .001). KAS revision led to greater racial diversity among recipients and donors, enhancing equity in organ allocation. However, disparities persist in graft failure rates and recipient survival across racial groups.

DISCUSSION

The 2014 Kidney Allocation System revision has led to important changes in the renal transplantation landscape. While progress has been made towards increasing racial equity in organ allocation, further refinements are needed to address ongoing disparities. Recognizing the changing patient profiles and socio-economic factors will be crucial in shaping future policy modifications.

African American race does not confer an increased risk of clinical events in patients with primary sclerosing cholangitis

BACKGROUND

The natural history of primary sclerosing cholangitis (PSC) among African Americans (AA) is not well understood.

METHODS

Transplant-free survival and hepatic decompensation-free survival were assessed using a retrospective research registry from 16 centers throughout North America. Patients with PSC alive without liver transplantation after 2008 were included. Diagnostic delay was defined from the first abnormal liver test to the first abnormal cholangiogram/liver biopsy. Socioeconomic status was imputed by the Zip code.

RESULTS

Among 850 patients, 661 (77.8%) were non-Hispanic Whites (NHWs), and 85 (10.0%) were AA. There were no significant differences by race in age at diagnosis, sex, or PSC type. Inflammatory bowel disease was more common in NHWs (75.8% vs. 51.8% p=0.0001). The baseline (median, IQR) Amsterdam-Oxford Model score was lower in NHWs (14.3, 13.4-15.2 vs. 15.1, 14.1-15.7, p=0.002), but Mayo risk score (0.03, -0.8 to 1.1 vs. 0.02, -0.7 to 1.0, p=0.83), Model for End-stage Liver Disease (5.9, 2.8-10.7 vs. 6.4, 2.6-10.4, p=0.95), and cirrhosis (27.4% vs. 27.1%, p=0.95) did not differ. Race was not associated with hepatic decompensation, and after adjusting for clinical variables, neither race nor socioeconomic status was associated with transplant-free survival. Variables independently associated with death/liver transplant (HR, 95% CI) included age at diagnosis (1.04, 1.02-1.06, p<0.0001), total bilirubin (1.06, 1.04-1.08, p<0.0001), and albumin (0.44, 0.33-0.61, p<0.0001). AA race did not affect the performance of prognostic models.

CONCLUSIONS

AA patients with PSC have a lower rate of inflammatory bowel disease but similar progression to hepatic decompensation and liver transplant/death compared to NHWs.