title: Predicting patient survival after deceased donor kidney transplantation using flexible parametric modelling.
abstract: The influence of donor and recipient factors on outcomes following kidney transplantation is commonly analysed using Cox regression models, but this approach is not useful for predicting long-term survival beyond observed data. We demonstrate the application of a flexible parametric approach to fit a model that can be extrapolated for the purpose of predicting mean patient survival. The primary motivation for this analysis is to develop a predictive model to estimate post-transplant survival based on individual patient characteristics to inform the design of alternative approaches to allocating deceased donor kidneys to those on the transplant waiting list in the United Kingdom.
  
  
  
  We analysed data from over 12,000 recipients of deceased donor kidney or combined kidney and pancreas transplants between 2003 and 2012. We fitted a flexible parametric model incorporating restricted cubic splines to characterise the baseline hazard function and explored a range of covariates including recipient, donor and transplant-related factors.
  
  
  
  Multivariable analysis showed the risk of death increased with recipient and donor age, diabetic nephropathy as the recipient's primary renal diagnosis and donor hypertension. The risk of death was lower in female recipients, patients with polycystic kidney disease and recipients of pre-emptive transplants. The final model was used to extrapolate survival curves in order to calculate mean survival times for patients with specific characteristics.
  
  
  
  The use of flexible parametric modelling techniques allowed us to address some of the limitations of both the Cox regression approach and of standard parametric models when the goal is to predict long-term survival.
authors.affiliation: Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. bernadette.li@lshtm.ac.uk.
authors.forename: Bernadette
authors.initials: B
authors.lastname: Li
authors.affiliation: Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
authors.forename: John A
authors.initials: JA
authors.lastname: Cairns
authors.affiliation: NHS Blood and Transplant, Bristol, UK.
authors.forename: Matthew L
authors.initials: ML
authors.lastname: Robb
authors.affiliation: NHS Blood and Transplant, Bristol, UK.
authors.forename: Rachel J
authors.initials: RJ
authors.lastname: Johnson
authors.affiliation: Department of Surgery, University of Cambridge and the NIHR Cambridge Biomedical Research Centre, Cambridge, UK.
authors.forename: Christopher J E
authors.initials: CJ
authors.lastname: Watson
authors.affiliation: Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK.
authors.forename: John L
authors.initials: JL
authors.lastname: Forsythe
authors.affiliation: Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK.
authors.forename: Gabriel C
authors.initials: GC
authors.lastname: Oniscu
authors.affiliation: Richard Bright Renal Unit, Southmead Hospital, Bristol, UK.
authors.forename: Rommel
authors.initials: R
authors.lastname: Ravanan
authors.affiliation: Richard Bright Renal Unit, Southmead Hospital, Bristol, UK.
authors.forename: Christopher
authors.initials: C
authors.lastname: Dudley
authors.affiliation: Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
authors.forename: Paul
authors.initials: P
authors.lastname: Roderick
authors.affiliation: Scottish Renal Registry, Glasgow, UK.
authors.forename: Wendy
authors.initials: W
authors.lastname: Metcalfe
authors.affiliation: Department of Renal Medicine, Freeman Hospital, Newcastle upon Tyne, UK.
authors.forename: Charles R
authors.initials: CR
authors.lastname: Tomson
authors.affiliation: Department of Surgery, University of Cambridge and the NIHR Cambridge Biomedical Research Centre, Cambridge, UK.
authors.forename: J Andrew
authors.initials: JA
authors.lastname: Bradley
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D003928:Diabetic Nephropathies / Q000150:complications / Q000453:epidemiology; D046148:Donor Selection; D005260:Female; D005544:Forecasting / Q000379:methods; D006801:Humans; D006973:Hypertension / Q000453:epidemiology; D016030:Kidney Transplantation / Q000379:methods / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D015999:Multivariate Analysis; D018579:Patient Selection; D007690:Polycystic Kidney Diseases / Q000150:complications / Q000453:epidemiology; D011184:Postoperative Period; D051436:Renal Insufficiency, Chronic / Q000209:etiology / Q000601:surgery*; D040841:Resource Allocation; D012307:Risk Factors; D012737:Sex Factors; D015996:Survival Rate; D055815:Young Adult
keywords: Extrapolation; Flexible parametric model; Kidney transplantation; Multivariable analysis; Survival