title: Quantifying the risk of incompatible kidney transplantation: a multicenter study.
abstract: Incompatible live donor kidney transplantation (ILDKT) offers a survival advantage over dialysis to patients with anti-HLA donor-specific antibody (DSA). Program-specific reports (PSRs) fail to account for ILDKT, placing this practice at regulatory risk. We collected DSA data, categorized as positive Luminex, negative flow crossmatch (PLNF) (n = 185), positive flow, negative cytotoxic crossmatch (PFNC) (n = 536) or positive cytotoxic crossmatch (PCC) (n = 304), from 22 centers. We tested associations between DSA, graft loss and mortality after adjusting for PSR model factors, using 9669 compatible patients as a comparison. PLNF patients had similar graft loss; however, PFNC (adjusted hazard ratio [aHR] = 1.64, 95% confidence interval [CI]: 1.15-2.23, p = 0.007) and PCC (aHR = 5.01, 95% CI: 3.71-6.77, p < 0.001) were associated with increased graft loss in the first year. PLNF patients had similar mortality; however, PFNC (aHR = 2.04; 95% CI: 1.28-3.26; p = 0.003) and PCC (aHR = 4.59; 95% CI: 2.98-7.07; p < 0.001) were associated with increased mortality. We simulated Centers for Medicare & Medicaid Services flagging to examine ILDKT's effect on the risk of being flagged. Compared to equal-quality centers performing no ILDKT, centers performing 5%, 10% or 20% PFNC had a 1.19-, 1.33- and 1.73-fold higher odds of being flagged. Centers performing 5%, 10% or 20% PCC had a 2.22-, 4.09- and 10.72-fold higher odds. Failure to account for ILDKT's increased risk places centers providing this life-saving treatment in jeopardy of regulatory intervention.
authors.affiliation: Departments of Surgery and Medicine, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: B J
authors.initials: BJ
authors.lastname: Orandi
authors.forename: J M
authors.initials: JM
authors.lastname: Garonzik-Wang
authors.forename: A B
authors.initials: AB
authors.lastname: Massie
authors.forename: A A
authors.initials: AA
authors.lastname: Zachary
authors.forename: J R
authors.initials: JR
authors.lastname: Montgomery
authors.forename: K J
authors.initials: KJ
authors.lastname: Van Arendonk
authors.forename: M D
authors.initials: MD
authors.lastname: Stegall
authors.forename: S C
authors.initials: SC
authors.lastname: Jordan
authors.forename: J
authors.initials: J
authors.lastname: Oberholzer
authors.forename: T B
authors.initials: TB
authors.lastname: Dunn
authors.forename: L E
authors.initials: LE
authors.lastname: Ratner
authors.forename: S
authors.initials: S
authors.lastname: Kapur
authors.forename: R P
authors.initials: RP
authors.lastname: Pelletier
authors.forename: J P
authors.initials: JP
authors.lastname: Roberts
authors.forename: M L
authors.initials: ML
authors.lastname: Melcher
authors.forename: P
authors.initials: P
authors.lastname: Singh
authors.forename: D L
authors.initials: DL
authors.lastname: Sudan
authors.forename: M P
authors.initials: MP
authors.lastname: Posner
authors.forename: J M
authors.initials: JM
authors.lastname: El-Amm
authors.forename: R
authors.initials: R
authors.lastname: Shapiro
authors.forename: M
authors.initials: M
authors.lastname: Cooper
authors.forename: G S
authors.initials: GS
authors.lastname: Lipkowitz
authors.forename: M A
authors.initials: MA
authors.lastname: Rees
authors.forename: C L
authors.initials: CL
authors.lastname: Marsh
authors.forename: B R
authors.initials: BR
authors.lastname: Sankari
authors.forename: D A
authors.initials: DA
authors.lastname: Gerber
authors.forename: P W
authors.initials: PW
authors.lastname: Nelson
authors.forename: J
authors.initials: J
authors.lastname: Wellen
authors.forename: A
authors.initials: A
authors.lastname: Bozorgzadeh
authors.forename: A O
authors.initials: AO
authors.lastname: Gaber
authors.forename: R A
authors.initials: RA
authors.lastname: Montgomery
authors.forename: D L
authors.initials: DL
authors.lastname: Segev
mesh_terms: D000328:Adult; D000906:Antibodies / Q000276:immunology*; D001787:Blood Group Incompatibility / Q000175:diagnosis / Q000453:epidemiology* / Q000276:immunology; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000209:etiology*; D006085:Graft Survival; D006680:HLA Antigens / Q000276:immunology*; D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000401:mortality / Q000601:surgery; D016030:Kidney Transplantation / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data*; D019520:Living Donors / Q000600:supply & distribution*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011379:Prognosis; D012307:Risk Factors; D015996:Survival Rate
chemical_list: D000906:Antibodies; D006680:HLA Antigens
keywords: Alloantibody; Scientific Registry for Transplant Recipients (SRTR); clinical research; graft survival; health services and outcomes research; kidney transplantation; law; legislation; living donor; nephrology; practice; simulation