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Observational Study
. 2021 Feb 1;105(2):436-442.
doi: 10.1097/TP.0000000000003254.

Center-level Variation in HLA-incompatible Living Donor Kidney Transplantation Outcomes

Kyle R Jackson  1 , Jane Long  1 , Jennifer Motter  1 , Mary G Bowring  1 , Jennifer Chen  1 , Madeleine M Waldram  1 , Babak J Orandi  2 , Robert A Montgomery  3 , Mark D Stegall  4 , Stanley C Jordan  5 , Enrico Benedetti  6 , Ty B Dunn  7 , Lloyd E Ratner  8 , Sandip Kapur  9 , Ronald P Pelletier  10 , John P Roberts  11 , Marc L Melcher  12 , Pooja Singh  13 , Debra L Sudan  14 , Marc P Posner  15 , Jose M El-Amm  16 , Ron Shapiro  17 , Matthew Cooper  18 , Jennifer E Verbesey  18 , George S Lipkowitz  19 , Michael A Rees  20 , Christopher L Marsh  21 , Bashir R Sankari  22 , David A Gerber  23 , Jason Wellen  24 , Adel Bozorgzadeh  25 , A Osama Gaber  26 , Eliot Heher  27 , Francis L Weng  28 , Arjang Djamali  29 , J Harold Helderman  30 , Beatrice P Concepcion  30 , Kenneth L Brayman  31 , Jose Oberholzer  31 , Tomasz Kozlowski  32 , Karina Covarrubias  33 , Niraj Desai  1 , Allan B Massie  1 , Dorry L Segev  1   34   35 , Jacqueline Garonzik-Wang  1
Affiliations
Observational Study

Center-level Variation in HLA-incompatible Living Donor Kidney Transplantation Outcomes

Kyle R Jackson et al. Transplantation. .

Abstract

Background: Desensitization protocols for HLA-incompatible living donor kidney transplantation (ILDKT) vary across centers. The impact of these, as well as other practice variations, on ILDKT outcomes remains unknown.

Methods: We sought to quantify center-level variation in mortality and graft loss following ILDKT using a 25-center cohort of 1358 ILDKT recipients with linkage to Scientific Registry of Transplant Recipients for accurate outcome ascertainment. We used multilevel Cox regression with shared frailty to determine the variation in post-ILDKT outcomes attributable to between-center differences and to identify any center-level characteristics associated with improved post-ILDKT outcomes.

Results: After adjusting for patient-level characteristics, only 6 centers (24%) had lower mortality and 1 (4%) had higher mortality than average. Similarly, only 5 centers (20%) had higher graft loss and 2 had lower graft loss than average. Only 4.7% of the differences in mortality (P < 0.01) and 4.4% of the differences in graft loss (P < 0.01) were attributable to between-center variation. These translated to a median hazard ratio of 1.36 for mortality and 1.34 of graft loss for similar candidates at different centers. Post-ILDKT outcomes were not associated with the following center-level characteristics: ILDKT volume and transplanting a higher proportion of highly sensitized, prior transplant, preemptive, or minority candidates.

Conclusions: Unlike most aspects of transplantation in which center-level variation and volume impact outcomes, we did not find substantial evidence for this in ILDKT. Our findings support the continued practice of ILDKT across these diverse centers.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1.
Figure 1.. Center-specific hazard ratios for post-ILDKT mortality, adjusting for patient-level characteristics
Although most centers had a post-ILDKT mortality risk that was indistinguishable from average, 6 (24%) centers had a significantly lower mortality risk than average, whereas 1 center (4%) had a significantly higher mortality risk than average, after adjusting for patient-level factors. ◊ Center whose post-ILDKT mortality risk was significantly different than average
Figure 2.
Figure 2.. Center-specific hazard ratios for post-ILDKT graft loss, adjusting for patient-level characteristics
Although most centers had a post-ILDKT graft loss risk that was indistinguishable from average, 5 (20%) centers had a significantly lower graft loss risk than average, whereas 2 centers (8%) had a significantly higher graft loss risk than average, after adjusting for patient-level factors. ◊ Center whose post-ILDKT graft loss risk was significantly different than average
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References

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    1. Orandi BJ, Luo X, Massie AB, et al. Survival Benefit with Kidney Transplants from HLA-Incompatible Live Donors. New England Journal of Medicine. 2016;374(10): 940–950. - PMC - PubMed
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