Many Patients With ESKD Are Not Placed on Kidney Transplant Waitlist Despite Eligibility

Eligible patients who are not waitlisted for kidney transplants lose profound opportunities and are subject to racial and socioeconomic disparities regarding waitlist placement, a study showed.

Many patients with end-stage kidney disease (ESKD) who have the longest expected posttransplant survival rate are not given a place on the kidney transplant waiting list in the United States, according to an analysis which appeared in the Journal of the American Society of Nephrology.

The Estimated Post Transplant Survival (EPTS) score employed through the kidney transplant allocation system identifies candidates who have achieved “top-20%” EPTS status and assigns them the highest quality deceased donor kidneys. Those who achieve this status have the longest expected posttransplant survival and receive preferential access to kidneys before other candidates.

An individual’s EPTS score is determined on a 0% to 100% scale by comparing candidates based on age, diabetes status, history of prior organ transplants, and time on dialysis. Younger candidates who do not have diabetes, have not had a previous transplant, and with little or no time on dialysis initially receive lower scores based on these criteria. The lower the score, the better.

An individual’s score is subject to change, such that an eligible candidate who achieves top-20% EPTS status may lose their eligibility over time. A lack of timely waitlist placement among eligible candidates may contribute to a loss of opportunity for improved quality of life and life expectancy.

To determine the rate of waitlist placement for patients who qualify for top-20% EPTS status, researchers gleaned data from the United States Renal Data System for all US adult patients who were preemptively listed (waitlisted before starting dialysis), or who initiated dialysis between 2015 and 2017. Researchers applied multivariable survival models to evaluate waitlist placement, transplantation, and mortality.

Of the 42,445 patients identified as having top-20% EPTS status, 7922 were preemptively listed and 34,523 initiated dialysis. Researchers observed that less than half of patients with ESKD with top-20% EPTS status received a spot on the transplant waiting list.

The 3-year cumulative incidence of waitlist placement for patients who initiated dialysis and achieved a top-20% EPTS status was 37%. However, the 3-year cumulative incidence of waitlist placement for patients with the lowest EPTS scores was higher than it was for those who achieved top-20% EPTS status, as rates were 48% for patients with EPTS 0% to 5% and 31% for patients with EPTS 16% to 20% at dialysis initiation.

The proportion of patients initiating dialysis who lost their top 20% EPTS status within 30 months was 61% compared with 18% of preemptively listed patients. Deceased and living donor transplantation rates for patients who initiated dialysis were 5% and 6%, respectively, compared with 25% and 44% for preemptively listed patients.

Findings shows that racial and socioeconomic disparities persist in waitlisting, as the population of nonlisted patients disproportionately consisted of African Americans, commercially uninsured individuals, and residents of low-income neighborhoods.

Among the 24% of patients who both initiated dialysis and were placed on the waiting list, many were younger, more likely to be Caucasian or Hispanic, and less likely to be primarily diagnosed with diabetes. They also had lower average EPTS scores at the time of dialysis initiation and earned higher residential median incomes.

Researchers concluded that many patients with ESKD who qualify to receive optimal deceased kidney donor transplants are not placed on the waiting list for kidney transplantation. These findings call attention to profound missed opportunities for improved quality of life and life expectancy for these patients. Further, disparities regarding demographic and socioeconomic background affects incidences of waitlist placement.

“These results are important to emphasize the need to develop more effective education, interventions, and policies to expedite access to transplantation for patients who would benefit and to attenuate longstanding disparities in these process of care,” lead author Jesse Schold, PhD, of the Cleveland Clinic, said in a statement.


Schold J, Huml A, Poggio E, et al. Profound opportunities lost: patients with high priority for transplant that are not placed on the kidney transplant waiting list. J Am Soc Nephrol. Published online June 17, 2021.

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