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Multicenter Study
. 2018 Feb;31(2):198-211.
doi: 10.1111/tri.13079. Epub 2017 Nov 2.

Center practice drives variation in choice of US kidney transplant induction therapy: a retrospective analysis of contemporary practice

Vikas R Dharnidharka  1 , Abhijit S Naik  2 , David A Axelrod  3 , Mark A Schnitzler  4 , Zidong Zhang  4 , Sunjae Bae  5 , Dorry L Segev  5 , Daniel C Brennan  5 , Tarek Alhamad  6 , Rosemary Ouseph  4 , Ngan N Lam  7 , Mustafa Nazzal  4 , Henry Randall  4 , Bertram L Kasiske  8 , Mara McAdams-Demarco  5 , Krista L Lentine  4
Affiliations
Multicenter Study

Center practice drives variation in choice of US kidney transplant induction therapy: a retrospective analysis of contemporary practice

Vikas R Dharnidharka et al. Transpl Int. 2018 Feb.

Abstract

To assess factors that influence the choice of induction regimen in contemporary kidney transplantation, we examined center-identified, national transplant registry data for 166 776 US recipients (2005-2014). Bilevel hierarchical models were constructed, wherein use of each regimen was compared pairwise with use of interleukin-2 receptor blocking antibodies (IL2rAb). Overall, 82% of patients received induction, including thymoglobulin (TMG, 46%), IL2rAb (22%), alemtuzumab (ALEM, 13%), and other agents (1%). However, proportions of patients receiving induction varied widely across centers (0-100%). Recipients of living donor transplants and self-pay patients were less likely to receive induction treatment. Clinical factors associated with use of TMG or ALEM (vs. IL2rAb) included age, black race, sensitization, retransplant status, nonstandard deceased donor, and delayed graft function. However, these characteristics explained only 10-33% of observed variation. Based on intraclass correlation analysis, "center effect" explained most of the variation in TMG (58%), ALEM (66%), other (51%), and no induction (58%) use. Median odds ratios generated from case-factor adjusted models (7.66-11.19) also supported large differences in the likelihood of induction choices between centers. The wide variation in induction therapy choice across US transplant centers is not dominantly explained by differences in patient or donor characteristics; rather, it reflects center choice and practice.

Keywords: immunosuppression; induction; kidney transplantation; practice patterns.

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Conflict of interest statement

DISCLOSURES/CONFLICTS OF INTEREST: The authors report no conflicts of interest.

Figures

None
Proportion of patients receiving each induction immunosuppression option (including no induction) across US transplant centers (2005–2014), by clinical risk profile
Figure 1
Figure 1
National trends in kidney transplant induction over time. IL2rAb, interleukin-2 receptor blocking antibodies.
Figure 2
Figure 2
National trends in kidney transplant induction by recipient immunologic risk profile. ALEM, alemtuzumab; IL2rAb, interleukin-2 receptor blocking antibodies; TMG, thymoglobulin. High risk was defined as black race, PRA >20, or retransplantation.
Figure 3
Figure 3
Proportion of patients receiving each induction immunosuppression option (including no induction) across US transplant centers (2005–2014). Each horizontal bar represents an individual center within US regions ordered by the proportion of patients receiving each regimen. Overall percentages of regimen use at patient level across centers: TMG, 46.0%; IL2rAb, 22.0%; ALEM, 12.5%; other induction, 1.3%; no induction, 18.2%. ALEM, alemtuzumab; IL2rAb, interleukin-2 receptor blocking antibodies; TMG, thymoglobulin.
Figure 4
Figure 4
Empirical Bayes estimates for likelihood of induction regimen use compared with IL2rAb. Reference regimen based on current US Food and Drug Administration approval. Red bar demonstrates national average rate of use of each regimen (within pairwise regimen comparisons). Each red dot represents adjusted use at one center and the blue bars reflect 95% confidence intervals for use at the center determined by empirical Bayes estimates, adjusting for case factors of transplants at the center; exclusion of the national average by a 95% confidence interval reflects adjusted center use significantly above or below the national average. ICC, intraclass correlation coefficient; IL2rAb, interleukin-2 receptor blocking antibodies; MOR, median odds ratio; TMG, thymoglobulin.
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References

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