The Long-term Effectiveness of the Kidney Allocation System

Abstract

Kidney transplant is considered the most beneficial treatment option for end-stage renal disease (ESRD), yet most ESRD patients in the United States do not receive a transplant. The demand for deceased donor kidneys far exceeds supply, therefore improving allocation of this scarce resource is critical. In 2014, a new Kidney Allocation System (KAS) was implemented to improve equity and outcomes of deceased donor kidney transplant (DDKT) in the US. The KAS sought to address specific issues with kidney allocation such as donor kidneys that fail early and thus require eventual re-transplantation, and excessive wait times for patients with late referral for transplant, difficult-to-match blood type, or highly sensitized patients. Several studies have described the initial changes in DDKT observed under the KAS. In the first year under the KAS, many patient subgroups experienced sharp increases in the probability of DDKT followed by subsequent years of less extreme differences. This thesis evaluates clinical and economic outcomes of two patient subgroups targeted by the KAS and describes new findings that are relevant to patients, clinicians, and policy makers. First, we find important differences in DDKT allocation by patient subgroup under the KAS. Next, we identify changes in return to work after transplant under the KAS among younger and sicker patients who were targeted by the policy. Finally, we provide a dynamic modeling structure for assessing long-term net benefits of the KAS that can be extended to other organ allocation policies.