Journey to kidney transplantation: patient dynamics, suspensions, transplantation and deaths in the Australian kidney transplant waitlist

Nicole L De La Mata; Victor Khou; James A Hedley; Patrick J Kelly; Rachael L Morton; Kate Wyburn; Angela C Webster

doi:10.1093/ndt/gfad253

Journey to kidney transplantation: patient dynamics, suspensions, transplantation and deaths in the Australian kidney transplant waitlist

Nephrol Dial Transplant. 2023 Nov 28:gfad253. doi: 10.1093/ndt/gfad253. Online ahead of print.

Authors

Nicole L De La Mata¹, Victor Khou¹, James A Hedley¹, Patrick J Kelly¹, Rachael L Morton², Kate Wyburn^{3

4}, Angela C Webster^{1

2

5}

Affiliations

¹ Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia.
² NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia.
³ Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia.
⁴ Renal Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
⁵ Centre for Renal and Transplant Research, Westmead Hospital, Sydney, NSW, Australia.

PMID: 38017628
DOI: 10.1093/ndt/gfad253

Abstract

Background and hypothesis: People on the kidney waitlist are less informed about potential suspensions. Disparities may exist among those who are suspended and who return to the waitlist. We evaluated the patient journey after entering the waitlist, including suspensions and outcomes, and factors associated with these transitions.

Methods: We included all incident patients waitlist for their first transplant from deceased donors in Australia, 2006-19. We described all clinical transitions after entering the waitlist. We predicted the restricted mean survival time (unadjusted and adjusted) until first transplant by number of prior suspensions. We evaluated factors associated with transitions using flexible survival models and clinical endpoints using Cox models.

Results: Of 8 466 patients waitlisted and followed over 45 757.4 person-years (median:4.8years), 6 741(80%) were transplanted, 381(5%) died waiting and 1 344(16%) were still waiting. 3 127(37%) people were suspended at least once. Predicted mean time from waitlist to transplant was 3.0 years(95%CI:2.8-3.2) when suspended versus 1.9 years(95%CI:1.8-1.9) when never suspended. Prior suspension increased likeliness of further suspensions 4.2-fold(95%CI:3.8-4.6) and returning to waitlist by 50%(95%CI:36-65%) but decreased likeliness of transplantation by 29%(95%CI:62-82%). Death risk while waiting was 12-fold(95%CI:8.0-18.3) increased when currently suspended. Australian non-Indigenous males were 13% (HR:1.13,95%CI:1.04-1.23) and Asian males 23% (HR:1.23,95%CI:1.06-1.42,) more likely to return to the waitlist compared to females of the same ethnicity.

Conclusion: The waitlist journey was not straightforward. Suspension was common, impacted chance of transplantation and meant waiting an average one year longer until transplant. We have provided estimates for, and factors associated with, suspension, re-listing and outcomes after waitlisting to support more informed discussions. This evidence is critical to further understand drivers of inequitable access to transplantation.

Keywords: Australia; kidney waitlist; outcomes; relisting; suspension.