Center-driven and Clinically Driven Variation in US Liver Transplant Maintenance Immunosuppression Therapy: A National Practice Patterns Analysis

Nazzal, Mustafa; Lentine, Krista L.; Naik, Abhijit S.; Ouseph, Rosemary; Zhang, Zidong; Randall, Henry B.; Dharnidharka, Vikas R.; Segev, Dorry L.; Kasiske, Bertram L.; Hess, Gregory P.; Alhamad, Tarek; McAdams‐DeMarco, Mara; Axelrod, David A.

doi:10.1097/txd.0000000000000800

Cited by 18 publications

(24 citation statements)

References 28 publications

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“…Center differences in maintenance IS strategies beyond that which is expected due to recipient factors have been demonstrated . However, practice patterns related to the recent increased use of induction therapy have not been investigated on a national level.…”

Section: Introductionmentioning

confidence: 99%

The use of induction therapy in liver transplantation is highly variable and is associated with posttransplant outcomes

Bittermann

Hubbard

Goldberg

2019

American Journal of Transplantation

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The use of induction immunosuppression in liver transplantation (LT) remains controversial. This was a retrospective cohort study of adult, first‐time liver‐alone recipients (N = 69 349) at 114 US centers between 2005 and 2018 using data from the United Network for Organ Sharing. The comparative effectiveness of nondepleting and depleting induction (NDI and DI) was assessed. Overall, 27% of recipients received induction with 65.7% of the variance in the receipt of induction being attributed to transplant center alone. NDI and DI were associated with a lower risk of death/graft failure compared to no induction (adjusted hazard ratio 0.90 [95% confidence interval (CI): 0.86‐0.95] and 0.91 [95% CI: 0.85‐0.97], respectively; P < .001). In nondialysis recipients at the mean transplant estimated glomerular filtration rate (eGFR), NDI was associated with an adjusted gain in eGFR by 6 months of +3.8 mL/min per 1.73 m2 and DI of +3.33 mL/min per 1.73 m2 compared to no induction (P < .001). Recipients with lower eGFR at LT had greater predicted improvement in eGFR (interaction P < .001). Only NDI was associated with a reduced risk of acute rejection in the first year post‐LT (odds ratio 0.87, 95% CI: 0.8‐0.94). Significant variability in induction practices exists, with center being a major determinant. The absolute incremental benefits of NDI and DI over no induction were small.

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Section: Introductionmentioning

confidence: 99%

The use of induction therapy in liver transplantation is highly variable and is associated with posttransplant outcomes

Bittermann

Hubbard

Goldberg

2019

American Journal of Transplantation

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“…Lastly, we noted that while some case‐level factors were associated with AHM use, the variation in use was almost entirely driven by prescribing practices of transplant centers. This finding is consistent with our previous studies highlighting and quantifying center‐level variation in immunosuppressive agent prescribing . Future studies are needed to specifically assess whether centers with the best short‐ and long‐term graft and patient outcomes employ certain practices and treatment patterns that drive those outcomes.…”

Section: Discussionmentioning

confidence: 80%

“…This finding is consistent with our previous studies highlighting and quantifying center-level variation in immunosuppressive agent prescribing. [9][10][11] Future studies are needed to specifically assess whether centers with the best short-and longterm graft and patient outcomes employ certain practices and treatment patterns that drive those outcomes.…”

Section: F I G U R Ementioning

confidence: 99%

“…8 This study was limited by an observation period (2005)(2006)(2007)(2008)(2009)(2010)) that preceded the 2014 Eighth Joint National Committee (JNC-8) hypertension guidelines, 6 and it did not consider the impact of transplant center variation practices. We recently identified center effect as a strong correlate of immunosuppressive regimen choice after transplant [9][10][11] and hypothesized that such center-driven variations may also affect AHM regimens.…”

Section: Introductionmentioning

confidence: 99%

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Impacts of center and clinical factors in antihypertensive medication use after kidney transplantation

Koraishy

Yamout

Naik

et al. 2020

Clinical Transplantation

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Hypertension guidelines recommend calcium channel blockers (CCBs), thiazide diuretics, and angiotensin‐converting‐enzyme inhibitors/angiotensin receptor blockers (ACEi/ARBs) as first‐line agents to treat hypertension. Hypertension is common among kidney transplant (KTx) recipients, but data are limited regarding patterns of antihypertensive medication (AHM) use in this population. We examined a novel database that links national registry data for adult KTx recipients (age > 18 years) with AHM fill records from a pharmaceutical claims warehouse (2007‐2016) to describe use and correlates of AHM use during months 7‐12 post‐transplant. For patients filling AHMs, individual agents used included: dihydropyridine (DHP) CCBs, 55.6%; beta‐blockers (BBs), 52.8%; diuretics, 30.0%; ACEi/ARBs, 21.1%; non‐DHP CCBs, 3.0%; and others, 20.1%. Both BB and ACEi/ARB use were significantly lower in the time period following the 2014 Eighth Joint National Committee (JNC‐8) guidelines (2014‐2016), compared with an earlier period (2007‐2013). The median odds ratios generated from case‐factor adjusted models supported variation in use of ACEi/ARBs (1.51) and BBs (1.55) across transplant centers. Contrary to hypertension guidelines for the general population, KTx recipients are prescribed relatively more BBs and fewer ACEi/ARBs. The clinical impact of this AHM prescribing pattern warrants further study.

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“…Immunosuppression after pediatric LT is dominantly driven by program preference, although patient or donor characteristics clearly affect initial regimen choice. 37 Children, with their longer life expectancy, experience greater cumulative exposure to immunosuppressive agents, thereby increasing their potential morbidity from these agents. While immunosuppression minimization or withdrawal has been a strategy adopted in response to the development of PTLD and other serious comorbidities, the literature is also revealing for many single-center reports of operationally tolerant patients-defined as those with serially normal liver function tests and serum transaminase levels.…”

Section: Allograft Healthmentioning

confidence: 99%

Barriers to ideal outcomes after pediatric liver transplantation

Mazariegos

Kelly

et al. 2019

Pediatric Transplantation

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Long‐term survival for children who undergo LT is now the rule rather than the exception. However, a focus on the outcome of patient or graft survival rates alone provides an incomplete and limited view of life for patients who undergo LT as an infant, child, or teen. The paradigm has now appropriately shifted to opportunities focused on our overarching goals of “surviving and thriving” with long‐term allograft health, freedom of complications from long‐term immunosuppression, self‐reported well‐being, and global functional health. Experts within the liver transplant community highlight clinical gaps and potential barriers at each of the pretransplant, intra‐operative, early‐, medium‐, and long‐term post‐transplant stages toward these broader mandates. Strategies including clinical research, innovation, and quality improvement targeting both traditional as well as PRO are outlined and, if successfully leveraged and conducted, would improve outcomes for recipients of pediatric LT.

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Center-driven and Clinically Driven Variation in US Liver Transplant Maintenance Immunosuppression Therapy: A National Practice Patterns Analysis

Abstract: Supplemental digital content is available in the text.

Cited by 18 publications

References 28 publications

The use of induction therapy in liver transplantation is highly variable and is associated with posttransplant outcomes

The use of induction therapy in liver transplantation is highly variable and is associated with posttransplant outcomes

Impacts of center and clinical factors in antihypertensive medication use after kidney transplantation

Barriers to ideal outcomes after pediatric liver transplantation

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