The unfinished journey toward transplant equity: an analysis of racial/ethnic disparities for children after the implementation of the Kidney Allocation System in 2014

Background: Disparities in pediatric kidney transplantation (KT) result in reduced access and worse outcomes for minority children. We assessed the impact of recent systems changes on these disparities. Methods: This is a retrospective cohort study of pediatric patients utilizing data from the US Renal Data System (n = 7547) and Scientific Registry of Transplant Recipients (n = 6567 waitlisted and n = 6848 transplanted patients). We compared access to transplantation, time to deceased donor kidney transplant (DDKT), and allograft failure (ACGF) in the 5 years preceding implementation of the Kidney Allocation System (KAS) to the 5 years post-KAS implementation 2010–2014 vs. 2015–2019, respectively. Results: Compared to the pre-KAS era, post-KAS candidates were more likely to be pre-emptively listed (26.8% vs. 38.1%, p < 0.001), pre-emptively transplanted (23.8% vs. 28.0%, p < 0.001), and less likely to have private insurance (35.6% vs. 32.3%, p = 0.01), but these were not uniform across racial groups. Compared to white children, Black and Hispanic children had a lower likelihood of transplant listing within 2 years of first dialysis service (aHR _0.590.67_0.76 and _0.730.82_0.92, respectively) in the post-KAS era. Time to DDKT was comparable across all racial groups in the post-KAS era. Compared to white children, Black DDKT recipients have more 5-year ACGF (aHR _1.001.43_2.06p = 0.05) while there was no difference in 3- or 5-year ACGF among LDKT recipients. Conclusions: After KAS implementation, there is equity in time to DDKT. Pre-KAS increased hazard of ACGF among Black children has decreased in the post-KAS era; however, persistent disparities exist in time to transplant listing among Black and Hispanic children when compared to white children. Graphical abstract: A higher resolution version of the Graphical abstract is available as Supplementary information [Figure not available: see fulltext.]