The pivotal impact of center characteristics on survival of candidates listed for deceased donor kidney transplantation

Abstract

Background: There are currently over half a million end-stage renal disease patients and >70,000 patients listed to receive a deceased donor kidney transplant in the United States. To receive a deceased donor transplant, patients are placed on a waiting list at one of approximately 240 centers. Although candidate decisions to list at a particular center may often be made passively (based on proximity or physician referral), the important question remains as to whether the center of listing has a significant impact on patient outcomes.

Methods: The study evaluated adult kidney transplant candidates in the United States listed from 1995 to 2000 (n = 108,928) with follow-up through 2006. The primary outcome of patient survival was investigated with survival models evaluated with respect to 4 center characteristics (volume, donor quality, waiting time, past performance). Center characteristics derived from years preceding listing, simulating information that could be attainable for prospective candidates.

Results: Center waiting time had a marked association with survival (Adjusted hazard ratio = 1.32, 95% confidence interval: 1.27-1.38 for the longest waiting times). Past performance and donor quality also had significant association with survival; center volume was not a significant factor. The cumulative impact of center factors resulted in an average 4-year difference in life expectancy. Center characteristics at listing were strongly correlated with levels at the time of transplantation and centers with the "best" characteristics were located in every region of the country.

Conclusions: Center characteristics have significant impact on kidney transplant candidate survival. Information regarding the variability and importance of center factors should be clearly disseminated to transplant candidates.