Major Variation across Local Transplant Centers in Probability of Kidney Transplant for Wait-Listed Patients

Abstract

BackgroundGeographic disparities in access to deceased donor kidney transplantation persist in the United States under the Kidney Allocation System (KAS) introduced in 2014, and the effect of transplant center practices on the probability of transplantation for wait-listed patients remains unclear.MethodsTo compare probability of transplantation across centers nationally and within donation service areas (DSAs), we conducted a registry study that included all United States incident adult kidney transplant candidates wait listed in 2011 and 2015 (pre-KAS and post-KAS cohorts comprising 32,745 and 34,728 individuals, respectively). For each center, we calculated the probability of deceased donor kidney transplantation within 3 years of wait listing using competing risk regression, with living donor transplantation, death, and waiting list removal as competing events. We examined associations between center-level and DSA-level characteristics and the adjusted probability of transplant.ResultsCandidates received deceased donor kidney transplants within 3 years of wait listing more frequently post-KAS (22%) than pre-KAS (19%). Nationally, the probability of transplant varied 16-fold between centers, ranging from 4.0% to 64.2% in the post-KAS era. Within DSAs, we observed a median 2.3-fold variation between centers, with up to ten-fold and 57.4 percentage point differences. Probability of transplantation was correlated in the post-KAS cohort with center willingness to accept hard-to-place kidneys (r=0.55, P<0.001) and local organ supply (r=0.44, P<0.001).ConclusionsLarge differences in the adjusted probability of deceased donor kidney transplantation persist under KAS, even between centers working with the same local organ supply. Probability of transplantation is significantly associated with organ offer acceptance patterns at transplant centers, underscoring the need for greater understanding of how centers make decisions about organs offered to wait-listed patients and how they relate to disparities in access to transplantation.

Greater complexity and monitoring of the new Kidney Allocation System: Implications and unintended consequences of concentric circle kidney allocation on network complexity

“…While this scenario currently occurs for imported organs, the frequent introduction of more than one OPO creates the need for more handoffs and the opportunity for communication error. With nearly 20% of deceased donor kidneys being discarded annually, and the high number of organ turn downs that appear to be unrelated to organ quality, there is already concern about organ utilization and the negative impact of the system design 9,12,19,20 . This process benefits from strong relationships between individual OPOs and transplant centers.…”

“…Perhaps more importantly, the perceived absence of a perceived benefit from listing at multiple centers within the boundaries of a single DSA will disappear and may encourage more multilisting. Changes in multilisting patterns (which are also influenced by center aggressiveness as well as nearby transplant center wait times) 9,22 and pursuit of living donation (as a result of differing allocation and perceptions of access) may identify differences that may otherwise go unrecognized in the absence of a robust process measurement plan.…”

“…In particular, transplant centers will have to work with more OPOs that service the increased number of donor hospitals that will now be considered to be “local” within the 250 nautical mile circles. These increased connections may adversely impact the strength of these relationships, at least at the outset, resulting in the unintended consequence of either increased discards or placement of kidneys lower on the match run, thereby exacerbating the subjectivity that is already adversely impacting the allocation of organs, access to transplantation, and patient outcomes 9,21 …”

“…These changes were not designed to address the geographic variation in access to transplantation, and so it is not surprising that geographic disparities persisted 8 . Variation in transplantation rates across the country has historically been attributed to differing local organ supply; however, marked variation in transplantation rates has been observed between centers within the same Donation Service Areas (DSAs) 9 . These differences appear to be related to organ offer acceptance/decline patterns that worsen geographic disparities 9,10 .…”

“…Variation in transplantation rates across the country has historically been attributed to differing local organ supply; however, marked variation in transplantation rates has been observed between centers within the same Donation Service Areas (DSAs) 9 . These differences appear to be related to organ offer acceptance/decline patterns that worsen geographic disparities 9,10 . Organ offers are most frequently declined due to poor organ quality; however, other reasons for declining organ offers include anatomic abnormalities, long cold ischemia time, surgical damage, and recipient readiness 11,12 .…”