title: Poor outcomes for children on the wait list at low-volume kidney transplant centers in the United States.
abstract: Low case volume has been associated with worse survival outcomes in solid organ transplantation. Our aim was to analyze wait-list outcomes in conjunction with posttransplant outcomes.
  
  
  
  We studied a cohort of 11,488 candidates waitlisted in the Organ Procurement and Transplantation Network (OPTN) for pediatric kidney transplant between 2002 and 2014, including both deceased- and living-donor transplants; 8757 (76 %) candidates received a transplant. Candidates were divided into four groups according to the average volume of yearly transplants performed in the listing center over a 12-year period: more than ten, six to nine, three to five, and fewer than three. We used multivariate Cox regression analysis to identify independent risk factors for wait list and posttransplant mortality.
  
  
  
  Twenty-seven percent of candidates were listed at low-volume centers in which fewer than three transplants were performed annually. These candidates had a limited transplant rate; only 49 % received a transplant versus 88 % in high-volume centers (more than ten transplants annually) (p < 0.001). Being listed at a low-volume center showed a fourfold increased risk for death while on the wait list [hazard ratio (HR) 4.0 in multivariate Cox regression and 6.1 in multivariate competing risk regression]. It was not a significant risk factor for posttransplant death in multivariate Cox regression.
  
  
  
  Pediatric transplant candidates are listed at low-volume transplant centers are transplanted less frequently and have a much greater risk of dying while on the wait list. Further studies are needed to elucidate the reasons behind the significant outcome differences.
authors.affiliation: Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, MS: BCM390, Houston, TX, 77030, USA. abbas.rana@bcm.edu.|Department of Surgery, Division of Abdominal Transplantation, Texas Children's Hospital, Houston, TX, USA. abbas.rana@bcm.edu.
authors.forename: Abbas
authors.initials: A
authors.lastname: Rana
authors.affiliation: Department of Pediatric Medicine, Division of Nephrology, Texas Children's Hospital, Houston, TX, USA.
authors.forename: Eileen D
authors.initials: ED
authors.lastname: Brewer
authors.affiliation: Department of Surgery, Division of Abdominal Transplantation, Texas Children's Hospital, Houston, TX, USA.
authors.forename: Brandi B
authors.initials: BB
authors.lastname: Scully
authors.affiliation: Department of Surgery, Division of Abdominal Transplantation, Texas Children's Hospital, Houston, TX, USA.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Kueht
authors.affiliation: Department of Surgery, Division of Abdominal Transplantation, Texas Children's Hospital, Houston, TX, USA.
authors.forename: Matt
authors.initials: M
authors.lastname: Goss
authors.affiliation: Department of Surgery, Division of Abdominal Transplantation, Weill Cornell Medical Center, New York, NY, USA.
authors.forename: Karim J
authors.initials: KJ
authors.lastname: Halazun
authors.affiliation: Dan L. Duncan Cancer Center, Department of Biostatistics, Baylor College of Medicine, Houston, TX, USA.
authors.forename: Hao
authors.initials: H
authors.lastname: Liu
authors.affiliation: Department of Surgery, Division of Abdominal Transplantation, Texas Children's Hospital, Houston, TX, USA.
authors.forename: N Thao N
authors.initials: NT
authors.lastname: Galvan
authors.affiliation: Department of Surgery, Division of Abdominal Transplantation, Texas Children's Hospital, Houston, TX, USA.
authors.forename: Ronald T
authors.initials: RT
authors.lastname: Cotton
authors.affiliation: Department of Surgery, Division of Abdominal Transplantation, Texas Children's Hospital, Houston, TX, USA.
authors.forename: Christine A
authors.initials: CA
authors.lastname: O'Mahony
mesh_terms: D000293:Adolescent; D000367:Age Factors; D015992:Body Mass Index; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003422:Critical Care; D005260:Female; D006085:Graft Survival; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007676:Kidney Failure, Chronic / Q000401:mortality / Q000601:surgery; D016030:Kidney Transplantation / Q000401:mortality / Q000706:statistics & numerical data*; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D014019:Tissue Donors / Q000706:statistics & numerical data; D009927:Tissue and Organ Procurement; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D014850:Waiting Lists
keywords: Case volume; Pediatric kidney transplant; Posttransplant survival; Transplant rate; Waitlist survival