Center practice drives variation in choice of US kidney transplant induction therapy: a retrospective analysis of contemporary practice

Abstract

To assess factors that influence the choice of induction regimen in contemporary kidney transplantation, we examined center-identified, national transplant registry data for 166 776 US recipients (2005-2014). Bilevel hierarchical models were constructed, wherein use of each regimen was compared pairwise with use of interleukin-2 receptor blocking antibodies (IL2rAb). Overall, 82% of patients received induction, including thymoglobulin (TMG, 46%), IL2rAb (22%), alemtuzumab (ALEM, 13%), and other agents (1%). However, proportions of patients receiving induction varied widely across centers (0-100%). Recipients of living donor transplants and self-pay patients were less likely to receive induction treatment. Clinical factors associated with use of TMG or ALEM (vs. IL2rAb) included age, black race, sensitization, retransplant status, nonstandard deceased donor, and delayed graft function. However, these characteristics explained only 10-33% of observed variation. Based on intraclass correlation analysis, "center effect" explained most of the variation in TMG (58%), ALEM (66%), other (51%), and no induction (58%) use. Median odds ratios generated from case-factor adjusted models (7.66-11.19) also supported large differences in the likelihood of induction choices between centers. The wide variation in induction therapy choice across US transplant centers is not dominantly explained by differences in patient or donor characteristics; rather, it reflects center choice and practice.

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

“…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.…”

“…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.…”

“…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.…”

Induction immunosuppression agents as risk factors for incident cardiovascular events and mortality after kidney transplantation

“…[13][14][15][16][17][18][19] Acute rejection after kidney transplantation is a risk factor for CVEs. Induction agents can be lymphocyte depleting, such as anti-thymocyte globulin (ATG) and alemtuzumab (AZM), or can prevent lymphocyte activation and replication, such as IL-2 receptor antagonist (IL-2RA).…”

“…T cell-depleting agents are associated with a lower incidence and severity of acute rejection. [13][14][15][16][17][18][19] Acute rejection after kidney transplantation is a risk factor for CVEs. [20][21][22] Thus, intuitively one would assume that use of T cell-depleting agents as induction therapy would be associated with lower rates of CVEs.…”