title: National Variation in Use of Immunosuppression for Kidney Transplantation: A Call for Evidence-Based Regimen Selection.
abstract: Immunosuppression management in kidney transplantation has evolved to include an increasingly diverse choice of medications. Although informed by patient and donor characteristics, choice of immunosuppression regimen varies widely across transplant programs. Using a novel database integrating national transplant registry and pharmacy fill records, immunosuppression use at 6-12 and 12-24 mo after transplant was evaluated for 22 453 patients transplanted in 249 U.S. programs in 2005-2010. Use of triple immunosuppression comprising tacrolimus, mycophenolic acid or azathioprine, and steroids varied widely (0-100% of patients per program), as did use of steroid-sparing regimens (0-77%), sirolimus-based regimens (0-100%) and cyclosporine-based regimens (0-78%). Use of triple therapy was more common in highly sensitized patients, women and recipients with dialysis duration >5 years. Sirolimus use appeared to diminish over the study period. Patient and donor characteristics explained only a limited amount of the observed variation in regimen use, whereas center choice explained 30-46% of the use of non-triple-therapy immunosuppression. The majority of patients who received triple-therapy (79%), cyclosporine-based (87.6%) and sirolimus-based (84.3%) regimens continued them in the second year after transplant. This population-based study of immunosuppression practice demonstrates substantial variation in center practice beyond that explained by differences in patient and donor characteristics.
authors.affiliation: Section of Solid Organ Transplantation, Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
authors.forename: D A
authors.initials: DA
authors.lastname: Axelrod
authors.affiliation: Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.
authors.forename: A S
authors.initials: AS
authors.lastname: Naik
authors.affiliation: Saint Louis University Center for Transplantation, Saint Louis University School of Medicine, St. Louis, MO.
authors.forename: M A
authors.initials: MA
authors.lastname: Schnitzler
authors.affiliation: Division of Abdominal Transplantation, Department of Surgery, Johns Hopkins University, Baltimore, MD.
authors.forename: D L
authors.initials: DL
authors.lastname: Segev
authors.affiliation: Division of Nephrology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO.
authors.forename: V R
authors.initials: VR
authors.lastname: Dharnidharka
authors.affiliation: Division of Nephrology, Department of Medicine, Washington University School of Medicine, St. Louis, MO.
authors.forename: D C
authors.initials: DC
authors.lastname: Brennan
authors.affiliation: Division of Abdominal Transplantation, Department of Surgery, Johns Hopkins University, Baltimore, MD.
authors.forename: S
authors.initials: S
authors.lastname: Bae
authors.affiliation: Center for Outcomes Research, Saint Louis University School of Medicine, St. Louis, MO.
authors.forename: J
authors.initials: J
authors.lastname: Chen
authors.affiliation: Division of Abdominal Transplantation, Department of Surgery, Johns Hopkins University, Baltimore, MD.
authors.forename: A
authors.initials: A
authors.lastname: Massie
authors.affiliation: Saint Louis University Center for Transplantation, Saint Louis University School of Medicine, St. Louis, MO.|Division of Nephrology, Department of Medicine, Saint Louis University School of Medicine, St. Louis, MO.
authors.forename: K L
authors.initials: KL
authors.lastname: Lentine
mesh_terms: D000328:Adult; D004359:Drug Therapy, Combination; D019317:Evidence-Based Medicine; D005260:Female; D005919:Glomerular Filtration Rate; D006084:Graft Rejection / Q000188:drug therapy* / Q000453:epidemiology; D006085:Graft Survival / Q000187:drug effects / Q000276:immunology; D006801:Humans; D007165:Immunosuppression Therapy / Q000379:methods*; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D007676:Kidney Failure, Chronic / Q000601:surgery*; D007677:Kidney Function Tests; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D015995:Prevalence; D011379:Prognosis; D012307:Risk Factors; D014181:Transplantation Immunology / Q000187:drug effects*
chemical_list: D007166:Immunosuppressive Agents
keywords: clinical research/practice; health services and outcomes research; immunosuppressant; immunosuppressive regimens; kidney transplantation/nephrology; maintenance; steroid