Delisting From the Kidney Transplant Waiting List: Impact on Patient Survival.

backgroundKidney transplant programs may remove high-risk patients from the national transplant waiting list to mitigate peri-transplant complications and enhance overall post-transplant survival. The phrase "too sick," frequently reported to the Organ Procurement and Transplantation Network (OPTN) as a reason for removal, lacks precision and specificity. Furthermore, there is limited information regarding the survival outcomes of patients who have been delisted and are consequently ineligible for a kidney transplant. In this study, we describe the specific reasons for delisting and investigate subsequent survival outcomes after being removed from the waiting list.

methodsData were collected from patients 18 years and older removed from the renal transplant waiting list between January 2011 and December 2015. Delisting categorization divided patients into a medical group (removed for clinical reasons such as cardiovascular disease, malignancy, or severe iliac calcification) and a psychosocial group (removed for issues such as patient request, non-compliance, insurance loss, or loss of contact). The primary endpoints were 5-year survival and restricted mean survival time (RMST) at 5 years.

resultsOut of 240 eligible patients, 124 patients (51.7%) were delisted for medical reasons and 116 (48.3%) were delisted for psychosocial reasons. Upon investigation, the primary reason for removal from the transplant waiting list among the medical group was cardiovascular (CV)-related comorbidities (44, 35.5%). 55% of the total number of patients delisted survived for 5 years. Patients delisted for medical reasons exhibited a 5-year survival rate of 43% and a RMST of 3.3 years. Specifically, patients delisted for CV-related reasons had a 5-year survival rate of 44%. In contrast, patients delisted for psychosocial reasons had a higher 5-year survival rate of 70% and a longer RMST of 4.31 years (p-value < 0.001). At 5 years following delisting, patients diagnosed with coronary artery disease (CAD) exhibited a 51% survival rate, which was significantly lower compared to those without CAD with a survival rate of 57% (p = 0.046).

conclusionCardiovascular disease remains the leading cause of delisting from the kidney transplant waiting list. However, many delisted patients demonstrated longer survival than expected. Further studies are needed to clarify the impact of delisting decisions on outcomes and to guide more informed, patient-centered transplant practices.