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Kidney transplant center volume shows no impact on clinical outcomes
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Receiving kidney transplantation at high-volume centers did not demonstrate improved graft or patient survival compared with transplantation at low-volume centers, according to a published study.
“One potentially valuable strategy to maximize the benefit of kidney transplantation is to identify centers that generate the best transplant outcomes and encourage patients to go to those centers,” Elizabeth M. Sonnenberg, MD, of the department of surgery at the University of Pennsylvania, and colleagues wrote. “Nephrologists often play an influential role in where their patients seek transplantation. During the past several decades, a variety of surgical fields have demonstrated improved outcomes at high-volume centers, leading some to recommend referral to high-volume centers.”
Researchers sought to investigate the potential relationship between transplant center volume and clinical outcomes. To do this, they used data from the Organ Procurement and Transplantation Network and conducted a retrospective cohort study of 79,581 adults who underwent transplantation between January 2009 and December 2013. Centers were categorized by volume as low (mean of two to 65 transplants per year), medium (66 to 110 per year), medium-high (111 to 195 per year) or high (198 to 315 per year). The primary outcomes of the study were all-cause graft failure and mortality within 3 years of transplantation.
Before adjusting for donor, recipient and graft characteristics, researchers observed minor differences in rates of both 3-year deceased donor graft failure and mortality across center volumes (graft failure: 14.9% for low-volume vs. 16.7% for high-volume centers; mortality: 9.1% for low-volume centers vs. 9.8% for high-volume centers). These results also applied to subgroups, including recipients with diabetes, those who were older and those who received high kidney donor profile index kidneys.
After adjustment, researchers determined that center volume did not significantly affect all-cause graft failure or mortality. They proposed that — unlike other surgical specialties — center volume may not impact outcomes after transplantation because transplant center care in the United States is “relatively homogenous,” transplantation surgeons undergo specialty training and/or regulatory oversight may quickly identify “quality outliers.”
“For nephrologists, who influence where patients seek a transplantation evaluation, these results would argue against referral to larger centers based on volume alone,” the researchers concluded. “Other patient-specific considerations, such as proximity to center, may matter more than center volume when selecting a center.”
In a related editorial, John R. Montgomery, MD, Randall S. Sung, MD, and Kenneth J. Woodside, MD, all of the University of Michigan, argued that the decision made by nephrologists as to which transplant centers best suit individual patients is a difficult one, complicated by many factors including comorbid conditions, distance to the center and average time on the waitlist.
“One question that frequently arises is whether transplantation center volume should drive patient referral patterns,” they wrote. “This study adds to the growing but complicated narrative of the relationship between transplantation center volume and postoperative outcomes ... Given the benefit of transplantation over dialysis even among low-performing centers, the highest priority is referring the patient to a kidney transplantation center appropriate to the patient’s level of complexity at which the patient is willing and able to receive care.” – by Melissa J. Webb
Disclosures: The authors report no relevant financial disclosures.
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