Victoria Socha

DocwireNews

For patients with kidney failure, kidney 
transplantation prolongs survival, improves quality of life, and reduces costs 
compared with dialysis. However, according to Elizabeth M. Sonnenberg, MD, and 
colleagues, there is a large gap between the demand for transplantation and 
supply of organs available. Identification of centers that are associated with 
the best outcomes of transplantation and encouraging patients to utilize those 
centers is a potentially valuable strategy for maximizing the benefit of 
transplantation.Previous studies have shown an 
association between improved outcomes and high-volume centers in a variety of 
surgical fields. However, there are few data revealing an association between 
kidney transplantation volume and survival. Dr. Sonnenberg et al. conducted a 
retrospective cohort study to examine whether a center volume-outcome relationship 
exists for contemporary kidney transplantation, specifically for recipients 
with diabetes, recipients &ge;65 years of age, and recipients of high kidney donor 
profile index (KDPI &ge;85) kidneys. The researchers sought to test the hypothesis 
that compared with low-volume centers, high-volume centers would have decreased 
graft failure and patient mortality. Results were reported in the American 
Journal of Kidney Diseases [2019; 74(4):441-451].The researchers utilized data from 
the Organ Procurement and Transplantation Network to identify a cohort of 
adults &ge;18 years of age who underwent kidney-only transplantation between 
January 1, 2009, and December 31, 2013. Transplantation centers were stratified 
into quartiles: Q1, low (annual range, 2-65); Q2, medium (annual range, 66-110); 
Q3, medium-high (annual range, 111-195); and Q4, high (annual range, 198-315). Centers 
performing &lt;10 transplantations during the study period were excluded. The 
primary outcomes of interest were all-cause graft failure and mortality within 
3 years of transplantation. Recipients of living and deceased donor organs were 
analyzed separately.The final cohort included 79,581 
kidney transplantations performed at 219 centers. Deceased donor 
transplantations constituted a lower proportion of transplantations at Q4 
centers compared with Q1 centers (57.1% vs 67.1%; P&lt;.001). Of their 
total deceased donor volume, Q4 centers used a greater proportion of high-KDPI 
kidneys compared with Q1 centers (12.5% vs 8.3%; P&lt;.001).There were slight variations in 
patient characteristics among the volume quartiles. Deceased donor grafts at Q4 
centers had longer cold ischemia times: 10.8% of grafts at Q4 centers had &le;36 
hours compared with 1.1% of grafts at Q1 centers. There were also variations in 
donor characteristics across volume quartiles. Deceased donor kidneys at Q4 
centers had higher median KDPI score compared with those used at Q1 centers (53 
vs 44; P&lt;.001). Q1 centers used a larger proportion of donation after 
cardiac death donors compared with Q4 centers (16.4% vs 13.6%; P&lt;.001).There were significant differences in 
unadjusted 3-year all-cause graft failure and mortality rates across volume 
quartiles. There were also significant differences across volume quartiles in 
unadjusted Cox models. The differences were small in absolute terms. Unadjusted 
rates of all-cause graft failure were 14.9% in Q1, 15.3% in Q2, 14.9% in Q3, 
and 16.7% in Q4. Rates of mortality were 9.1% in Q1, 8.8% in Q2, 8.4% in Q3, 
and 9.8% in Q4.In analyses of graft failure, center 
volume had a borderline statistically significant interaction with recipients 
with diabetes (interaction term P=.05) and high-KDPI kidney recipients 
(interaction term P=.05). There was no interaction between recipient age 
and center volume for either outcome.A total of 5128 recipients with 
diabetes who received a deceased donor transplant (38.1% of all deceased donor 
transplants) received care at a Q1 center; 3973 recipients with diabetes who 
received a deceased donor transplant (35.3% of all deceased donor recipients) 
were treated at a Q4 center. While not clinically meaningful, there were 
significant differences across volume quartile in unadjusted 3-year all-cause 
graft failure and mortality rates. The highest unadjusted rates of all-cause 
graft failure were in Q4 centers (19.7% vs 18.4%, 18,1%, and 17.7% in Q1, Q2, 
and Q3 centers, respectively; P=.02); rates of mortality were also 
highest in Q4 centers (13.8% vs 13.2%, 12.6%, and 11.7% in Q1, Q2, and Q3 
centers, respectively; P=.01).Because low-volume centers 
transplanted a larger proportion of deceased donor organs, all quartiles used a 
substantial number of high-KDPI kidneys: 1117 at Q1 centers versus 1401 at Q4 
centers. In unadjusted analysis of 3-year all-cause graft failure and mortality 
rates of high-KDPI kidneys, the rates were lowest for Q3 centers: all-cause 
graft failure in Q3 centers, 23.3% versus 26.5% for Q1 centers, 28.0% for Q2 
centers, and 26.5% for Q4 centers; mortality in Q3 centers, 13.0% versus 16.0% 
at Q1 centers, 17.5% at Q2 centers, and 15.0% at Q4 centers. There was no 
significant effect of center volume on all-cause graft failure and mortality in 
multivariable Cox frailty models.There were some limitations to the 
study, including unmeasured confounding from patient comorbid conditions and 
organ selection and the potential for measurement errors in registry data.In conclusion, the researchers said, 
&ldquo;This study found no evidence that increased center volume was associated with 
improved outcomes for kidney transplant recipients. Importantly, this finding 
remained consistent among increased-risk recipients and increased-risk donors. 
For nephrologists, who influence where patients seek a transplantation 
evaluation, these results would argue against referral to larger centers based on 
volume alone. Other patient-specific considerations, such as proximity to 
center, may matter more than center volume when selecting a center. Additional 
research is needed to understand qualities and practices of transplantation 
centers that generate superior outcomes for patients.&rdquo;Takeaway Points<ol class="wp-block-list">
<li>Researchers conducted a retrospective cohort study to test the hypothesis that high-volume kidney transplantation centers would generate superior outcomes compared with low-volume centers.</li>
<li>In multivariable Cox regression models, there was no significant association between center volume and all-cause graft failure or mortality within 3 years post-transplantation.</li>
<li>Transplant recipients with diabetes had slightly lower 3-year mortality rates at centers with medium-high volume compared with centers with low volume (adjusted hazard ratio, 0.85; 95% confidence interval, 0.73-0.99).</li>
</ol>

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Kidney Transplant Center Volume and 3-Year Clinical Outcomes

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For patients with kidney failure, kidney transplantation prolongs survival, improves quality of life, and reduces costs compared with dialysis. 

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