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. 2015 May;99(5):997-1002.
doi: 10.1097/TP.0000000000000450.

Center-level variation in the development of delayed graft function after deceased donor kidney transplantation

Babak J Orandi  1 , Nathan T James, Erin C Hall, Kyle J Van Arendonk, Jacqueline M Garonzik-Wang, Natasha Gupta, Robert A Montgomery, Niraj M Desai, Dorry L Segev
Affiliations

Center-level variation in the development of delayed graft function after deceased donor kidney transplantation

Babak J Orandi et al. Transplantation. 2015 May.

Abstract

Background: Patient-level risk factors for delayed graft function (DGF) have been well described. However, the Organ Procurement and Transplantation Network definition of DGF is based on dialysis in the first week, which is subject to center-level practice patterns. It remains unclear if there are center-level differences in DGF and if measurable center characteristics can explain these differences.

Methods: Using the 2003 to 2012 Scientific Registry of Transplant Recipients data, we developed a hierarchical (multilevel) model to determine the association between center characteristics and DGF incidence after adjusting for known patient risk factors and to quantify residual variability across centers after adjustment for these factors.

Results: Of 82,143 deceased donor kidney transplant recipients, 27.0% developed DGF, with a range across centers of 3.2% to 63.3%. A center's proportion of preemptive transplants (odds ratio [OR], 0.83; per 5% increment; 95% confidence interval [95% CI], 0.74-;0.93; P = 0.001) and kidneys with longer than 30 hr of cold ischemia time (CIT) (OR, 0.95; per 5% increment; 95% CI, 0.92-;0.98; P = 0.001) were associated with less DGF. A center's proportion of donation after cardiac death donors (OR, 1.12; per 5% increment; 95% CI, 1.03-;1.17; P < 0.001) and imported kidneys (OR, 1.06; per 5% increment; 95% CI, 1.03-;1.10; P < 0.001) were associated with more DGF. After patient-level and center-level adjustments, only 41.8% of centers had DGF incidences consistent with the national median and 28.2% had incidences above the national median.

Conclusion: Significant heterogeneity in DGF incidences across centers, even after adjusting for patient-level and center-level characteristics, calls into question the generalizability and validity of the current DGF definition. Enhanced understanding of center-level variability and improving the definition of DGF accordingly may improve DGF's utility in clinical care and as a surrogate endpoint in clinical trials.

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Conflict of interest statement

Conflict of Interest Disclosures: The authors have no relevant disclosures or conflicts of interest.

Figures

Figure 1
Figure 1
Relative likelihood of DGF, based on (A) a model that only includes patient-level characteristics and (B) a model that combines patient and center-level characteristics, by center. A displays the log odds of DGF at a center relative to the national median based on adjustment for patient-level characteristics. Based on this model, 38.4% (68/177) of centers have 95% confidence intervals that encompass the national median log odds of DGF. The relative log odds ranged from -2.20-1.11 (IQR:-0.44-0.31), which corresponds to a relative odds of DGF range across centers of 0.11-3.02 (IQR: 0.64-1.37). B displays the log odds of DGF at a center relative to the national median based on adjustment for patient and center-level characteristics. Based on this model, 41.8% (74/177) of centers have 95% confidence intervals that encompass the national median log odds of DGF. The relative log odds ranged from -1.50-1.12 (IQR: -0.34-0.34), which corresponds to a relative odds of DGF range across centers of 0.22-3.08 (IQR: 0.71-1.41). DGF=delayed graft function, IQR=interquartile range
Figure 1
Figure 1
Relative likelihood of DGF, based on (A) a model that only includes patient-level characteristics and (B) a model that combines patient and center-level characteristics, by center. A displays the log odds of DGF at a center relative to the national median based on adjustment for patient-level characteristics. Based on this model, 38.4% (68/177) of centers have 95% confidence intervals that encompass the national median log odds of DGF. The relative log odds ranged from -2.20-1.11 (IQR:-0.44-0.31), which corresponds to a relative odds of DGF range across centers of 0.11-3.02 (IQR: 0.64-1.37). B displays the log odds of DGF at a center relative to the national median based on adjustment for patient and center-level characteristics. Based on this model, 41.8% (74/177) of centers have 95% confidence intervals that encompass the national median log odds of DGF. The relative log odds ranged from -1.50-1.12 (IQR: -0.34-0.34), which corresponds to a relative odds of DGF range across centers of 0.22-3.08 (IQR: 0.71-1.41). DGF=delayed graft function, IQR=interquartile range
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References

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