Access to the Kidney Transplant Waitlist for People With HIV

The Advisory Committee on Blood and Tissue Safety and Availability recently voted to remove the statutory National Institutes of Health research criteria and institutional review board requirements for performing kidney transplantation using kidneys from donors with HIV. This policy change may subsequently increase utilization of such organs.1 Despite excellent kidney transplant outcomes, single-center studies have demonstrated significantly lower kidney transplant waitlist addition rates for people with HIV (PWH) in the United States as compared with those without HIV, a requisite step for deceased donor kidney transplantation.2-4 Should adoption of transplantation using kidneys from donors with HIV increase following the implementation of this policy, understanding waitlist addition nationally is imperative. Acknowledging the lack of granularity in HIV-specific data, we used the United States Renal Data System and accompanying Medicare claims data to identify a cohort of PWH (January 1, 2007–December 31, 2016) with end-stage kidney disease (ESKD) and compared waitlist addition rates among PWH with ESKD patients without HIV. This study was approved by the Institutional Review Board at the University of Alabama at Birmingham. Among 602 006 incident patients whose primary payer was Medicare,5 HIV status was defined using the Chronic Conditions Data Warehouse algorithm (sensitivity: 93.2%; specificity: 99.4%). PWH with claims for an opportunistic infection within 90 d of dialysis initiation were excluded. Cox proportional hazards and Fine and Gray competing risks regressions were used to examine the likelihood of waitlist addition. The 6250 PWH were younger, more commonly African American, and more commonly reported alcohol dependence, drug dependence, and tobacco use. Cumulative incidence of waitlist addition within 5 y of dialysis initiation was 11.1% among PWH and 15.3% among ESKD patients without HIV. Following adjustment for demographics, comorbid conditions, and geography, HIV was associated with 52% lower likelihood of waitlist addition (adjusted hazard ratio: 0.48; 95% confidence interval, 0.43-0.52; P < 0.001; Table 1). After accounting for competing risks of death and living donor kidney transplantation before waitlist addition, a similar inequity was observed (adjusted subdistribution hazard ratio: 0.45; 95% confidence interval, 0.42-0.49; P < 0.001). TABLE 1. - Unadjusted and adjusted likelihood of waitlist addition among ESKD patients within 5 y and within all observed time following dialysis initiation 5 y, HR (95% CI) a Full follow-up, HR (95% CI) a Unadjusted PWH (ref: HIV–) 0.90 (0.83-0.98) 0.64 (0.54-0.75) PWH (ref: HIV–) b 0.93 (0.86-0.99) 0.62 (0.58-0.68) aHR (95% CI) b aHR (95% CI) b Adjusted PWH (ref: HIV–) 0.48 (0.43-0.52) 0.27 (0.21-0.35) PWH (ref: HIV–) b 0.45 (0.42-0.49) 0.25 (0.20-0.32) Bold values indicate significance at P < 0.05.aAdjusted for age, race, ethnicity, sex, WHO obesity class, alcohol abuse, drug abuse, diabetes, hypertension, cancer, peripheral vascular disease, nonambulatory status, assistance needed for daily activities, atherosclerotic heart disease, cerebrovascular disease, amputation, coronary obstructive pulmonary disease, institutionalized (yes/no), functional status, tobacco use, rurality, ESKD network, and year of dialysis initiation.bCompeting risk model.aHR, adjusted HR; CI, confidence interval; ESKD, end-stage kidney disease; HIV–, HIV negative; HR, hazard ratio; PWH, people with HIV; WHO, World Health Organization. This disparity in waitlist addition experienced by PWH has been described in single-center data,2-4 and commonly attributed to clinical factors, specifically severity of HIV infection as defined by CD4 counts, HIV viral loads, presence of opportunistic infections, substance use, and failure to complete transplant evaluation. Reported substance use was included in our analysis, but, despite attempts to account for HIV-specific characteristics through the exclusion of PWH with opportunistic infections, we were unable to completely account for such, nor could we assess where this disparity manifests, including referral rates or evaluation completions. Reliance upon Medicare claims data also resulted in an older cohort, potentially resulting in lower waitlist addition rates. Thus, the magnitude of the disparity between PWH and ESKD patients with HIV may have been overestimated or developed earlier at referral or evaluation. Despite these limitations, this observed inequity is confirmed by studies that collected HIV-specific characteristics, referral, and evaluation data. Given advances in transplantation for PWH, national data collection should be revised to capture early steps in transplantation and HIV-specific characteristics to ensure equitable access to and outcomes of transplantation.2-4