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

Kyle R. Jackson; Jane Long; Jennifer Motter; Mary G. Bowring; Jennifer Chen; Madeleine M. Waldram; Babak J. Orandi; Robert A. Montgomery; Mark D. Stegall; Stanley C. Jordan; Enrico Benedetti; Ty B. Dunn; Lloyd E. Ratner; Sandip Kapur; Ronald P. Pelletier; John P. Roberts; Marc L. Melcher; Pooja Singh; Debra L. Sudan; Marc P. Posner; Jose M. El-Amm; Ron Shapiro; Matthew Cooper; Jennifer E. Verbesey; George S. Lipkowitz; Michael A. Rees; Christopher L. Marsh; Bashir R. Sankari; David A. Gerber; Jason Wellen; Adel Bozorgzadeh; A. Osama Gaber; Eliot Heher; Francis L. Weng; Arjang Djamali; J. Harold Helderman; Beatrice P. Concepcion; Kenneth L. Brayman; Jose Oberholzer; Tomasz Kozlowski; Karina Covarrubias; Niraj Desai; Allan B. Massie; Dorry L. Segev; Jacqueline Garonzik-Wang

doi:10.1097/TP.0000000000003254

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

Kyle R. Jackson, Jane Long, Jennifer Motter, Mary G. Bowring, Jennifer Chen, Madeleine M. Waldram, Babak J. Orandi, Robert A. Montgomery, Mark D. Stegall, Stanley C. Jordan, Enrico Benedetti, Ty B. Dunn, Lloyd E. Ratner, Sandip Kapur, Ronald P. Pelletier, John P. Roberts, Marc L. Melcher, Pooja Singh, Debra L. Sudan, Marc P. PosnerJose M. El-Amm, Ron Shapiro, Matthew Cooper, Jennifer E. Verbesey, George S. Lipkowitz, Michael A. Rees, Christopher L. Marsh, Bashir R. Sankari, David A. Gerber, Jason Wellen, Adel Bozorgzadeh, A. Osama Gaber, Eliot Heher, Francis L. Weng, Arjang Djamali, J. Harold Helderman, Beatrice P. Concepcion, Kenneth L. Brayman, Jose Oberholzer, Tomasz Kozlowski, Karina Covarrubias, Niraj Desai, Allan B. Massie, Dorry L. Segev, Jacqueline Garonzik-Wang

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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.

Original language	English
Pages (from-to)	436-442
Number of pages	7
Journal	Transplantation
Volume	105
Issue number	2
DOIs	https://doi.org/10.1097/TP.0000000000003254
State	Published - Feb 1 2021

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10.1097/TP.0000000000003254

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Jackson, K. R., Long, J., Motter, J., Bowring, M. G., Chen, J., Waldram, M. M., Orandi, B. J., Montgomery, R. A., Stegall, M. D., Jordan, S. C., Benedetti, E., Dunn, T. B., Ratner, L. E., Kapur, S., Pelletier, R. P., Roberts, J. P., Melcher, M. L., Singh, P., Sudan, D. L., ... Garonzik-Wang, J. (2021). Center-level Variation in HLA-incompatible Living Donor Kidney Transplantation Outcomes. Transplantation, 105(2), 436-442. https://doi.org/10.1097/TP.0000000000003254

@article{72043c49b97944708223223bd4b96829,

title = "Center-level Variation in HLA-incompatible Living Donor Kidney Transplantation Outcomes",

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.",

author = "Jackson, {Kyle R.} and Jane Long and Jennifer Motter and Bowring, {Mary G.} and Jennifer Chen and Waldram, {Madeleine M.} and Orandi, {Babak J.} and Montgomery, {Robert A.} and Stegall, {Mark D.} and Jordan, {Stanley C.} and Enrico Benedetti and Dunn, {Ty B.} and Ratner, {Lloyd E.} and Sandip Kapur and Pelletier, {Ronald P.} and Roberts, {John P.} and Melcher, {Marc L.} and Pooja Singh and Sudan, {Debra L.} and Posner, {Marc P.} and El-Amm, {Jose M.} and Ron Shapiro and Matthew Cooper and Verbesey, {Jennifer E.} and Lipkowitz, {George S.} and Rees, {Michael A.} and Marsh, {Christopher L.} and Sankari, {Bashir R.} and Gerber, {David A.} and Jason Wellen and Adel Bozorgzadeh and Gaber, {A. Osama} and Eliot Heher and Weng, {Francis L.} and Arjang Djamali and Helderman, {J. Harold} and Concepcion, {Beatrice P.} and Brayman, {Kenneth L.} and Jose Oberholzer and Tomasz Kozlowski and Karina Covarrubias and Niraj Desai and Massie, {Allan B.} and Segev, {Dorry L.} and Jacqueline Garonzik-Wang",

note = "Funding Information: 34Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD. 35Scientific Registry of Transplant Recipients, Minneapolis, MN. *These authors contributed equally to this work This work was supported by grant numbers F32DK113719 (Jackson), K01DK101677 (Massie), RO1DK098431 (Segev), K24DK101828 (Segev), and K23DK115908 (Garonzik-Wang) from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Dr. Garonzik-Wang is supported by a Clinician Scientist Development Award from the Doris Duke Charitable Foundation. The authors declare no conflicts of interest. K.R.J. participated in research design, data acquisition, statistical analysis, writing the article, and editing the article. J.L., J.M., and M.G.B. participated in data acquisition, statistical analysis, and comprehensive editing of the article. J.C., M.M.W., B.J.O., R.A.M., M.D.S., S.C.J., E.B., T.B.D., L.E.R., S.K., R.P.P., J.P.R., M.L.M., P.S., D.L.S., M.P.P., J.M.E.-A., R.S., M.C., J.E.V., G.S.L, M.A.R., C.L.M., B.R.S., D.A.G., J.W., A.B., A.O.G., E.H., F.L.W., A.D., J.H.H., B.P.C., K.L.B., J.O., T.K., K.C., and N.D. participated in data acquisition and comprehensive editing of the article. A.B.M., D.L.S., and J.G.-W. participated in research design, contributed analytical tools, and comprehensive editing of the article. Correspondence: Jacqueline Garonzik-Wang, MD, PhD, Johns Hopkins Medical Institutions, 720 Rutland Ave, Ross 771D, Baltimore, MD 21205. (jgaronz1@ jhmi.edu). Copyright {\textcopyright} 2020 Wolters Kluwer Health, Inc. All rights reserved. Publisher Copyright: {\textcopyright} 2021 Lippincott Williams and Wilkins. All rights reserved.",

year = "2021",

month = feb,

day = "1",

doi = "10.1097/TP.0000000000003254",

language = "English",

volume = "105",

pages = "436--442",

journal = "Transplantation",

issn = "0041-1337",

number = "2",

}

Jackson, KR, Long, J, Motter, J, Bowring, MG, Chen, J, Waldram, MM, Orandi, BJ, Montgomery, RA, Stegall, MD, Jordan, SC, Benedetti, E, Dunn, TB, Ratner, LE, Kapur, S, Pelletier, RP, Roberts, JP, Melcher, ML, Singh, P, Sudan, DL, Posner, MP, El-Amm, JM, Shapiro, R, Cooper, M, Verbesey, JE, Lipkowitz, GS, Rees, MA, Marsh, CL, Sankari, BR, Gerber, DA, Wellen, J, Bozorgzadeh, A, Gaber, AO, Heher, E, Weng, FL, Djamali, A, Helderman, JH, Concepcion, BP, Brayman, KL, Oberholzer, J, Kozlowski, T, Covarrubias, K, Desai, N, Massie, AB, Segev, DL & Garonzik-Wang, J 2021, 'Center-level Variation in HLA-incompatible Living Donor Kidney Transplantation Outcomes', Transplantation, vol. 105, no. 2, pp. 436-442. https://doi.org/10.1097/TP.0000000000003254

TY - JOUR

T1 - Center-level Variation in HLA-incompatible Living Donor Kidney Transplantation Outcomes

AU - Jackson, Kyle R.

AU - Long, Jane

AU - Motter, Jennifer

AU - Bowring, Mary G.

AU - Chen, Jennifer

AU - Waldram, Madeleine M.

AU - Orandi, Babak J.

AU - Montgomery, Robert A.

AU - Stegall, Mark D.

AU - Jordan, Stanley C.

AU - Benedetti, Enrico

AU - Dunn, Ty B.

AU - Ratner, Lloyd E.

AU - Kapur, Sandip

AU - Pelletier, Ronald P.

AU - Roberts, John P.

AU - Melcher, Marc L.

AU - Singh, Pooja

AU - Sudan, Debra L.

AU - Posner, Marc P.

AU - El-Amm, Jose M.

AU - Shapiro, Ron

AU - Cooper, Matthew

AU - Verbesey, Jennifer E.

AU - Lipkowitz, George S.

AU - Rees, Michael A.

AU - Marsh, Christopher L.

AU - Sankari, Bashir R.

AU - Gerber, David A.

AU - Wellen, Jason

AU - Bozorgzadeh, Adel

AU - Gaber, A. Osama

AU - Heher, Eliot

AU - Weng, Francis L.

AU - Djamali, Arjang

AU - Helderman, J. Harold

AU - Concepcion, Beatrice P.

AU - Brayman, Kenneth L.

AU - Oberholzer, Jose

AU - Kozlowski, Tomasz

AU - Covarrubias, Karina

AU - Desai, Niraj

AU - Massie, Allan B.

AU - Segev, Dorry L.

AU - Garonzik-Wang, Jacqueline

N1 - Funding Information: 34Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD. 35Scientific Registry of Transplant Recipients, Minneapolis, MN. *These authors contributed equally to this work This work was supported by grant numbers F32DK113719 (Jackson), K01DK101677 (Massie), RO1DK098431 (Segev), K24DK101828 (Segev), and K23DK115908 (Garonzik-Wang) from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Dr. Garonzik-Wang is supported by a Clinician Scientist Development Award from the Doris Duke Charitable Foundation. The authors declare no conflicts of interest. K.R.J. participated in research design, data acquisition, statistical analysis, writing the article, and editing the article. J.L., J.M., and M.G.B. participated in data acquisition, statistical analysis, and comprehensive editing of the article. J.C., M.M.W., B.J.O., R.A.M., M.D.S., S.C.J., E.B., T.B.D., L.E.R., S.K., R.P.P., J.P.R., M.L.M., P.S., D.L.S., M.P.P., J.M.E.-A., R.S., M.C., J.E.V., G.S.L, M.A.R., C.L.M., B.R.S., D.A.G., J.W., A.B., A.O.G., E.H., F.L.W., A.D., J.H.H., B.P.C., K.L.B., J.O., T.K., K.C., and N.D. participated in data acquisition and comprehensive editing of the article. A.B.M., D.L.S., and J.G.-W. participated in research design, contributed analytical tools, and comprehensive editing of the article. Correspondence: Jacqueline Garonzik-Wang, MD, PhD, Johns Hopkins Medical Institutions, 720 Rutland Ave, Ross 771D, Baltimore, MD 21205. (jgaronz1@ jhmi.edu). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. Publisher Copyright: © 2021 Lippincott Williams and Wilkins. All rights reserved.

PY - 2021/2/1

Y1 - 2021/2/1

N2 - 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.

AB - 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.

UR - http://www.scopus.com/inward/record.url?scp=85089456346&partnerID=8YFLogxK

U2 - 10.1097/TP.0000000000003254

DO - 10.1097/TP.0000000000003254

M3 - Article

C2 - 32235255

AN - SCOPUS:85089456346

SN - 0041-1337

VL - 105

SP - 436

EP - 442

JO - Transplantation

JF - Transplantation

IS - 2

ER -

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

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