Center-Level Variation in HLA-Incompatible Living Donor Kidney Transplantation Outcomes

K. Jackson¹, J. Long¹, K. Covarrubias¹, J. Motter¹, M. Bowring¹, J. Chen¹, M. Waldram¹, B. Orandi², N. Desai¹, A. Massie¹, D. Segev¹, J. Garonzik-Wang¹

¹Johns Hopkins University, Baltimore, MD, ²University of Alabama School of Medicine, Birmingham, AL

Meeting: 2019 American Transplant Congress

Abstract number: 446

Keywords: Graft survival, Histocompatibility, Kidney

Session Information

Session Name: Concurrent Session: Kidney Living Donor: Long Term Outcomes

Session Type: Concurrent Session

Date: Tuesday, June 4, 2019

Session Time: 2:30pm-4:00pm

Presentation Time: 2:42pm-2:54pm

Location: Room 304

*Purpose: Desensitization protocols for HLA-incompatible living donor kidney transplantation (ILDKT) vary across centers. The impact of these variations, as well as other practice variations, on ILDKT outcomes remain unknown. We sought to quantify center-level variation in patient and graft survival following ILDKT.

*Methods: Using a 25-center cohort augmented by linkage to SRTR, we studied 1,358 ILDKT recipients transplanted between 1997-2016 and compared patient and graft survival across centers. Between-center differences in patient and graft survival were compared with a multi-level Cox model using shared frailty, allowing each center to have a different underlying hazard of mortality and graft loss. Between-center variation was quantified using the median hazard ratio (MHR), which describes the median increase in the risk of mortality or graft loss when comparing a patient at a center with higher risk to a center with lower risk.

*Results: Only 5 centers (20%) had significantly better outcomes than average, and only 1 center (4%) had worse patient survival, and 2 centers (8%) had worse graft survival, than average (Figure). After adjusting for patient-level characteristics, only 9.9% of the differences in patient survival (p<0.01), and 9.2% of the differences in graft survival (p<0.01), were attributable to between-center variation. These translated to a MHR of 1.36 for patient mortality, and 1.34 for graft loss. For perspective, the magnitude of these between-center differences was similar to the effect of a 10-year increase in recipient age on mortality (adjusted hazard ratio: _1.281.37_1.46, p<0.001). There was no relationship between the following center-level characteristics and improved outcomes: transplanting a higher proportion of highly sensitized recipients, prior transplant recipients, pre-emptive recipients, racial minorities, or performing a higher IKT volume.

*Conclusions: Unlike most aspects of transplantation which have very high center-level variation, we found almost no center-level variation in ILDKT outcomes. Importantly, we found no center volume effect. Our findings support the continued practice of ILDKT across these diverse centers.

To cite this abstract in AMA style:

Jackson K, Long J, Covarrubias K, Motter J, Bowring M, Chen J, Waldram M, Orandi B, Desai N, Massie A, Segev D, Garonzik-Wang J. Center-Level Variation in HLA-Incompatible Living Donor Kidney Transplantation Outcomes [abstract]. Am J Transplant. 2019; 19 (suppl 3). https://atcmeetingabstracts.com/abstract/center-level-variation-in-hla-incompatible-living-donor-kidney-transplantation-outcomes/. Accessed November 21, 2024.

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